examination of the motor system
TRANSCRIPT
EXAMINATION OF THE MOTOR SYSTEM DR BISWA RANJAN PATRA
RESIDENT OF MEDICINEPGIMER amp DR RML HOSPITAL
NEW DELHI
WHY DO WE DO A MOTOR SYSTEM EXAMINATION
Cardinal symptoms and signs which prompt a motor system examination
1 Weakness
2 Imbalance
3 In-coordination
4 As a part of CNS examination
OUTLINEbull Anatomy
bull Inspection and Palpation
bull Tone and Power
bull Reflexes
bull Posture and abnormal movements
bull Coordination
bull Stance and gait
ANATOMY
COMPONENTS
1 CORTICOSPINAL CORTICOBULBAR
2 EXTRAPYRAMIDAL SYSTEM
3 NEUROMUSCULAR UNIT
ORGANIZATION OF MOTOR SYSTEM
CORTICOSPINAL AND CORTICOBULBAR Corticobulbar (corticonuclear) fibers
Originate in the region of the sensorimotor cortex where the face is represented They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets the somatic and brachial efferent nuclei in the brain stem
Corticospinal tract
Originates in the remainder of the sensorimotor cortex and other cortical areas It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence the name pyramidal tract) decussates and descends in the lateral column of the spinal cord
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
WHY DO WE DO A MOTOR SYSTEM EXAMINATION
Cardinal symptoms and signs which prompt a motor system examination
1 Weakness
2 Imbalance
3 In-coordination
4 As a part of CNS examination
OUTLINEbull Anatomy
bull Inspection and Palpation
bull Tone and Power
bull Reflexes
bull Posture and abnormal movements
bull Coordination
bull Stance and gait
ANATOMY
COMPONENTS
1 CORTICOSPINAL CORTICOBULBAR
2 EXTRAPYRAMIDAL SYSTEM
3 NEUROMUSCULAR UNIT
ORGANIZATION OF MOTOR SYSTEM
CORTICOSPINAL AND CORTICOBULBAR Corticobulbar (corticonuclear) fibers
Originate in the region of the sensorimotor cortex where the face is represented They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets the somatic and brachial efferent nuclei in the brain stem
Corticospinal tract
Originates in the remainder of the sensorimotor cortex and other cortical areas It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence the name pyramidal tract) decussates and descends in the lateral column of the spinal cord
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
OUTLINEbull Anatomy
bull Inspection and Palpation
bull Tone and Power
bull Reflexes
bull Posture and abnormal movements
bull Coordination
bull Stance and gait
ANATOMY
COMPONENTS
1 CORTICOSPINAL CORTICOBULBAR
2 EXTRAPYRAMIDAL SYSTEM
3 NEUROMUSCULAR UNIT
ORGANIZATION OF MOTOR SYSTEM
CORTICOSPINAL AND CORTICOBULBAR Corticobulbar (corticonuclear) fibers
Originate in the region of the sensorimotor cortex where the face is represented They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets the somatic and brachial efferent nuclei in the brain stem
Corticospinal tract
Originates in the remainder of the sensorimotor cortex and other cortical areas It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence the name pyramidal tract) decussates and descends in the lateral column of the spinal cord
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
ANATOMY
COMPONENTS
1 CORTICOSPINAL CORTICOBULBAR
2 EXTRAPYRAMIDAL SYSTEM
3 NEUROMUSCULAR UNIT
ORGANIZATION OF MOTOR SYSTEM
CORTICOSPINAL AND CORTICOBULBAR Corticobulbar (corticonuclear) fibers
Originate in the region of the sensorimotor cortex where the face is represented They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets the somatic and brachial efferent nuclei in the brain stem
Corticospinal tract
Originates in the remainder of the sensorimotor cortex and other cortical areas It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence the name pyramidal tract) decussates and descends in the lateral column of the spinal cord
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
COMPONENTS
1 CORTICOSPINAL CORTICOBULBAR
2 EXTRAPYRAMIDAL SYSTEM
3 NEUROMUSCULAR UNIT
ORGANIZATION OF MOTOR SYSTEM
CORTICOSPINAL AND CORTICOBULBAR Corticobulbar (corticonuclear) fibers
Originate in the region of the sensorimotor cortex where the face is represented They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets the somatic and brachial efferent nuclei in the brain stem
Corticospinal tract
Originates in the remainder of the sensorimotor cortex and other cortical areas It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence the name pyramidal tract) decussates and descends in the lateral column of the spinal cord
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
ORGANIZATION OF MOTOR SYSTEM
CORTICOSPINAL AND CORTICOBULBAR Corticobulbar (corticonuclear) fibers
Originate in the region of the sensorimotor cortex where the face is represented They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets the somatic and brachial efferent nuclei in the brain stem
Corticospinal tract
Originates in the remainder of the sensorimotor cortex and other cortical areas It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence the name pyramidal tract) decussates and descends in the lateral column of the spinal cord
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
CORTICOSPINAL AND CORTICOBULBAR Corticobulbar (corticonuclear) fibers
Originate in the region of the sensorimotor cortex where the face is represented They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets the somatic and brachial efferent nuclei in the brain stem
Corticospinal tract
Originates in the remainder of the sensorimotor cortex and other cortical areas It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence the name pyramidal tract) decussates and descends in the lateral column of the spinal cord
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
EXTRAPYRAMIDAL SYSTEM
Clinical phenomena of patients with disorders of extrapyramidal system are different than those with pyramidal
Principal component is basal ganglia and its connections
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
BASAL GANGLIA Components
1 Globus Pallidus
2 Putamen
3 Caudate
4 Substantia Nigra
5 Subthalamic Nucleus
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
FUNCTIONS OF BASAL GANGLIA Voluntary movement
Initiation of movement Change from one pattern to other Programming and correcting movement while in progress (thalamocortical circuts)
Postural control Righting reflex Automatic associated movement (walking)
Control of muscle tone Reticulospinal Vestibulospinal
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
NEUROMUSCULAR UNIT
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
MUSCLE VOLUME amp CONTOUR
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Muscle volume and contour may be appraised by inspection palpation and measurement
INSPECTION- compare symmetric parts for any flattening hollowing or bulging of the muscles masses
- faceshoulder amp pelvic girdle palmar surface of hand thenar and hypothenar eminence interossous muscles
PALPATION- assess muscle bulk contour amp consistency- semielastic and regain their shape at once when compressed
MEASUREMENTS- made from fixed points and compared bilaterally (10 cm abovebelow olecranon 18cm above 10 cm below tibial tuberosity)
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
MUSCLE TONE
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
MUSCLE TONE It is the resistance to passive motion due to inherent attributes of muscles- viscosity
elasticity extensibility
Resting muscle tone is greatest in antigravity muscles that maintain the body in erect posture
It is by interplay by the gamma motor neuron loop in spinal cord segment amp descending influences from higher motor centres
Loss of impulses from the supraspinal pathways that normally inhibit lower reflex centers usually causes an increase in tone
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
EXAMINATION OF TONEUPPER LIMBS
Undulating flexion-extension movement at wrist amp elbow joint
Supination pronation of forearm- PRONATOR CATCH- in spaticity
Hand dropping test- look for checking movements
LOWER LIMBS
Rolling of limbs- floppy side to side movements ankle amp foot move in a piece
Passive flexion extension of hip knee amp ankle
Brisk flexion of knee joint upwards- heel slides leg rises all in one
Leg dropping test- normal checking movements
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
PENDULOUSNESS OF LEGS- There will normally be a swinging of the legs that progressively diminishes in range and usually disappears after six or seven oscillations
In extrapyramidal rigidity there is a decrease in swing time but usually no qualitative change in the response
In spasticity there may be little or no decrease in swing time but the movements are jerky and irregular- zigzag pattern
HEAD DROPPING TEST- Normally head drops rapidily into examiners hand
in extrapyramidal rigidity- delayedslow gentle dropping rigidity affecting flexors
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
SPACTICITY- greater in one group of muscle than other (not uniform throughout the range of movement) varies with the speed of movement (velocity dependent)
CLASP-KNIFE PRONATER CATCH (spacticity of pronator muscles)
LEAD-PIPE RIGIDITY PLASTIC- equal resistance in both agonist amp antagonist independent of the rate of movement
COGWHEEL RIGIDITY- jerky quality to hypertonicity the jerky quality of the resistance may be due to tremor superimposed on lead-pipe rigidity
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
MOTOR STRENGTH AND POWER
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Strength evaluation requires-
-judgment of force exerted in either initiating or resisting movement (MAJOR CRITERIA)
-observation palpation of either the contraction of the muscle belly or movements of its tendon
Strength evaluation being subjective is AT BEST SEMIQUANTITATIVE with significant inter amp intraexaminer variability
For more quantitative determinations various dynamometers myometers and ergometers are available
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
The strength examination assesses primarily voluntary or active muscle contraction rather than reflex contraction
Strength may be classified as
-kinetic (the force exerted in changing position) and
-static (the force exerted in resisting movement from a fixed position)
In most disease processes both are equally affected and the two methods can be used interchangeably
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Misleads Extrapyramidal disease- rigidity bradykinesia
Hyperkinesia ataxia
Speed ndash hypohyperthyroidism depression
Motor impersistence- apraxia
Lossimpairment of movement- pain swelling spasm fractures dislocations ankylosis contractures
Passive movements to assess range of motion are necessary before strength evaluation
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
In COMA assessment of motor function depends on
-spontaneous movements
-position of an extremity
-withdrawal of an extremity in response to painful stimulation
-any asymmetry of spontaneous or reflex movements on the two sides
HEMIPLEGIA
-absence of contraction of the facial muscles on one side following pressure on the supraorbital ridge
-the flail dropping of the wrist and forearm when released
-extension and external rotation of the thigh and leg when released
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
STRENGTH SCALES
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Variability in muscle power size gender body built affect examiners as well as patients
STRENGTH MISMATCH
General principle- reliable strength testing should attempt to break a given muscle
-Muscles are most powerful when maximally shortened
-Lever effect (using a long lever rather than a short lever to overpower a muscle )
The small hand muscles are best examined by matching them against the examinerrsquos like muscle
The gastrocnemius muscles are normally so powerful it is virtually useless to examine them using hand and arm strength
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
PATTERN OF WEAKNESS Generalized weakness- involves both sides of the body more or less symmetrically
truly generalized weakness involve bulbar motor functions
Lesion can be in spinal cordperipheral nervesNm junctionmyopathy
Spinal cord disease involve muscles preferentially innervated by CST neuropathy (distalgtproximal) myopathy amp Nm junction (proximalgtdistal)
Focal weakness- hemiparesis monoparesis diplegia (weakness of like parts bilaterally)
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
NONORGANIC WEAKNESS HOOVER (AUTOMATIC WALKING) SIGN
Hooverrsquos sign is absence of the expected associated movement
- flexionextension counter movement (hip)
- adductionadduction (hip)
- abductionabduction (hip)
Muscle tone is normal decreased amp usually vary from time to time
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
UMN vs LMN Isolated contraction of a single muscle is rarely possible because muscles with
similar functions participate in almost every movement
UMN Lesions- Pyramidal lesions disrupt movements any muscle that participates in the movement will be weakened regardless of its specific lower motor neuron innervation
In contrast LMN lesions involve muscles innervated by a specific structure such as a nerve root or peripheral nerve
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
MUSCLES OF THE NECK Principal neck movements are flexion extension (retraction) rotation (turning) and
lateral bending (tilting abduction)
Except for the sternocleidomastoid (SCM) and trapezius it is not possible to examine them individually
The spinal accessory nerve along with the second third and fourth cervical segments supplies both muscles
SCM is a flexor and rotator of the head and neck the trapezius retracts the neck and draws it to one side
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
The neck flexion test consists of measuring the time the supine patient can keep the head raised with the chin on the chest
Most patients can keep their head in this position for at least 1 minute
Evaluation of myopathies and neuromuscular junction disorders- cause neck flexor or extensor weakness
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THE SCAPULA Elevate- upper fibers of trapezius levator scapulae
Depression- lower fibers of trapezius pectoralis minor subclavius
Retraction- rhomboids middle fibers of trapezius
Protraction- serratius anterior pectoralis minor
Examination of the rhomboids is important in the differentiation of C5 radiculopathy from upper trunk brachial plexopathy
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Dorsal scapular nerve C45Retraction of scapulaThe rhomboids can be tested by having the patient with hand on hip retract the shoulder against the examinerrsquos attempt to push the elbow forward
RHOMBOIDS
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Cranial XI C234Upper fibers- shrugMiddle fibers-retractOn retraction of the shoulder against resistance the middle fibers of the muscle can be seen and palpated
TRAPEZIUS
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Long thoracic nerve- C57Protraction of scapulaThe patient pushes against a wall with his arms extended horizontally in front of him normally the medial border of the scapula remains close to the thoracic wall
SERRATIUS ANTERIOR
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
WINGING OF SCAPULA Weakness of either the serratus anterior or the trapezius
Trapezius retracts during abduction of the arm serratus anterior functions during forward elevation
Trapezius winging- patient bend forward at the waist so the upper body is parallel to the ground then raise the arms to the sides as if beginning a swan dive
Serratus anterior- trying to elevate the arm in frontprotract scapula against resitance
Muscular dystrophies- facioscapulohumeral (FSH) dystrophy there is often weakness of all the shoulder girdle muscles with prominent scapular winging typically bilateral
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
For demonstrating winging of scapula due to weakness in trapezius
SWAN DIVE POSTURE
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THE GLENOHUMERAL JOINT Abduct- supraspinatus deltoid trapezius serratus anterior
Adduct- pectoralis major latismus dorsi
Flexion- pectoralis major anterior fibres of deltoid
Extension-posterior fibres of deltoid lattismus dorsi
Internal rotation- subscapularis teres major
External rotation- infraspinatus teres minor
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Suprascapular nerve C56
Contraction of the muscle fibers can be felt during early stages of abduction of the arm
SUPRASPINATUS
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Axilliary nerve C56Abduction 15 to 90 degreesThe patient attempts to abduct his arm against resistance the contracting deltoid can be seen and palpated
DELTOID
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Lateral amp medial pectoral nerveC5-T1Contraction of the muscle can be seen and felt during attempts to adduct the arm against resistance
PECTORALIS MAJOR
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Thoracodorsal nerve C6-8Adducts extends medially rotates shoulder
On adduction of the horizontally and laterally abducted arm against resistance the contracting muscle fibers can be seen and palpated
LATTISMUS DORSI
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THE ELBOW Flexion- Biceps brachii- (flexion power greatest when forearm is supinated )
Brachialis- (flexes regardless of forearm position)
Brachioradialis- (flexor when semipronated forearm -thumb up)
Extension- tricepsanconeus
Supination- Biceps (strongest when forearm is flexed amp pronated)
Supinator (acts through all degrees of flexion amp supination)
Brachioradialis (forearm extended amp pronated)
Pronation- Pronator quadratus (in extension)
Pronator teres (in flexon)
Brachioradialis (forearm flexed amp supinated)
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Musculocutaneous nerve C56Flexion supinationOn attempts to flex the forearm against resistance the contracting biceps muscle can be seen and palpated
BICEPS BRACHII
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Radial nerve C56Flexion supinator pronatorOn flexion of the semipronated forearm (thumb up) against resistance the contracting muscle can be seen and palpated
BRACHIORADIALIS
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Radial nerve C678Extension of elbow jointOn attempts to extend the partially flexed forearm against resistance contraction of the triceps can be seen and palpated
TRICEPS
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
A On attempts to supinate the extended forearm against resistance the contracting brachioradialis can be seen amp PalpatedB supinate the flexed forearm against resistance the contracting biceps can be seen amp palpatedC On pronation of the forearm against resistance contraction of the Pronator Teres can be seen and palpated
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THE WRIST Flexion- FCR FCU
Extension- ECRLECRBECU
Adduction (ulnar flexion)- ECU
Abduction (radial flexion)- ECRLECRB
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
FCRFCU palpated ECRLECU palpated
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
FINGERS Flexion- FDS (flexes PIP)
FDP (flexes DIP)
Interossei amp lumbricals flex MCP and extend IP joints
GRIP POWER
Making a fist requires flexion of the fingers at all joints (MCPIPThumb)
It is not very useful in assessing upper extremity motor function
Grip strength is unaffected by CST pathology as finger and wrist flexors are not CST innervated and are not likely to be weak with a mild CST lesion
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
FINGER FLEXORS
FDP-The patient resists attempts to extend the distal phalanges while the middle phalanges are fixed
FDS- The patient resists attempts to straighten the fingers at the first Interphalangeal (IP) joint
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
EDC- With hand outstretched and IP joints held in extension the patient resists the examinerrsquos attempt to flex the fingers at the (MCP) joints
Lumbricals amp Interossei- Extension of the middle and distal phalanges the patient attempts to extend the fingers against resistance while the MCP joints are fixed
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THUMB MUSCLE Forearm muscle- APL- abduct thumb amp extend it
EPL- extend terminal phalanx
EPB- extend proximal phalynx
FPL
Thenar muscle- APBOPFLB
Palmar abduction by APL amp APB muscles
Radial abduction by APL amp EPB muscles
Opposition- OPODM
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
FPL- The patient resists attempts to extend the distal phalanx of the thumb while the proximal phalanx is fixedEPL- The patient attempts to resist passive flexion of the thumb at the IP joint the tendon can be seen and palpatedEPB-The patient attempts to resist passive flexion of the thumb at the MCP joint the tendon can be seen and palpated
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Radial abduction of the thumb The patient attempts to abduct the thumb in the same plane as that of the palm the tendon of the APL can be seen and palpated
Palmar abduction of the thumb The patientattempts against resistance to bring the thumb to a point vertically above its original position
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
OP- The patient attempts against resistance to touch the tip of the little finger with the thumbODM-The patient attempts to move the extended little finger in front of the other fingers and toward the thumbPalmar interossei - Adduction of the fingers The patient attempts to adduct the fingers against resistance
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
MUSCLES OF ABDOMEN Rectus abdominis pyramidalis transverse abdominis amp oblique (external amp internal)
BEEVOR SIGN
InT10 myelopathy the upper abdominal muscles will pull the umbilicus cephalad when the patient raises the head or attempts a sit-up
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
T7-T12 intercostal nervesThe recumbent patient attempts to raise his head against resistanceFlexors of spine also involved
ABDOMINAL MUSCLES
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THE HIP JOINT Flexors- iliopsoas rectus femoris Sartorius tensor fascia lata
Extensors- gluteus maximus
Abductors- gluteus medius minimus TFL
Adductors- adductor magnuslongus brevis
Internalmedial rotator- hip abductor muscles- gluteus medius minimus TFL
Externallateral rotator- gluteus maximus obturator internus amp externus
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Femoral nerve L2-4The patient attempts to flex the thigh against resistance the knee is flexed and the leg rests on the examinerrsquos armWith legs fixed they flex the trunk and pelvis forward Normal hip flexors cannot be overcome by an examiner using hand and arm strength from an armrsquos length awayLEG DRIFT- UL CST lesion- flexed hip extended knee- 45 degree drift downward
FLEXORS OF THIGH
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Inferior gluteal nerve L5-S2The patient lying prone with the leg flexed at the knee attempts to extend the thigh against resistance contraction of the gluteus maximus and other extensors can be seen and palpatedHaving the knee flexed minimizes any contribution from the hamstringsLying in side amp extending hip stand upright from a stooped position
GOWERS MANEUVER- using his hands to ldquoclimb up the legsrdquo Seen in muscular dystrophies with marked weakness of hip extensors
EXTENSORS OF THIGH
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Superior gluteal nerve L4-S1TRENDELENBURGrsquoS SIGN Exacerbated pelvic swing during the stance phase as the pelvis on the side of the swing leg drops downwardsBilateral- pelvic waddle WADDLING GAIT
ABDUCTION OF THIGH AT HIP
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Obturator nerve L2-4AMagnus- Sciatic N carrying L45 The recumbent patient attempts to adduct the extended leg against resistance contraction of the adductor muscles can be seen and palpated
ADDUCTORS OF THIGH AT THE HIP
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Superior gluteal nerve L4-S1The patient lying prone with the leg flexed at the knee attempts to carry the foot laterally against resistance thus rotating the thigh mediallyPreferentially CST innervated muscle EXTERNALLATERAL ROTATIONG Maximus inferior gluteal nerveRotate medially with flexed knee
INTERNALMEDIAL ROTATION
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THE KNEE JOINT Flexion- hamstring muscles (biceps femoris semimembranosus semitendinosus)
The hamstrings also act as powerful hip extensors
Extensors- Quadriceps femoris
(rectus femoris vastus lateralismedialisintermedius)
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Sciatic nerve L5S1 S2The prone patient attempts to maintain flexion of the leg while the examiner attempts to extend it the tendon of the biceps femoris can be palpated laterally and the tendons of the semimembranosus and semitendinosus medially
LEG DRIFT LEG SIGN OF BARREProne both knee flexed at 45 degree from horizontal with CST lesion involved leg will sink
FLEXION AT THE KNEE
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Femoral nerve L2-4The supine patient attempts to extend the leg at the knee against resistance contraction of the quadriceps femoris can be seen and palpated
EXTENSION AT KNEE
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
The quadriceps is very powerfulIt is capable of generating as much as 1000 pounds of forcemdashthree times more than the hamstrings
The quadriceps is so powerful it is nearly impossible to overcome in the normal adolescent or adult except by taking extreme mechanical advantage
A sometimes useful technique for testing knee extension is the ldquoBARKEEPERrsquoS HOLDrdquo a hold usually applied to the elbow to controlunruly patrons
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
THE ANKLE JOINT Plantarflexion- gastrocnemius soleus
Dorsiflexionextension- tibialis anterior EDL EHL
Inversion- tibialis posterior (platarflexed) tibialis anterior (dorsiflexed)
Eversion- peronei longus brevis tertius EDL
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Tibial nerve S1-S2The patient attempts to plantarflex the foot at the ankle joint against resistance contraction of the gastrocnemius and associated muscles can be seen and palpatedVery powerful muscles mechanical advantage need to be taken with long lever Patient stand on tiptoe
PLANTARFLEXION OF THE FOOT
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Deep peroneal nerve L4-L5 The patient attempts to dorsiflex the foot against resistance contraction of the tibialis anterior can be seen and palpatedPatient standing on heels raising toeSTEPPAGE GAIT exaggerated flexion at hip amp knee to clear groundAudible double slapAlso in sensory ataxia
DERSIFLEXIONEXTENSION OF THE FOOT
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Tibialis posterior Tibial nerve L5-S1
The patient attempts to raise the inner border of the foot against resistance the tendon of the tibialis posterior can be seen and palpated just behind the medial malleolus
INVERSION OF THE FOOT
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
P longus brevis- superficial peroneal nerve L5L5S1P tertius- deep peroneal nerve
The patient attempts to raise the outer border of the foot against resistance the tendons of the peronei longus and brevis can be seen and palpated just above and behind the lateral malleolus
EVERSION OF THE FOOT
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
MUSCLES OF FOOT amp TOES The function of individual foot and toe muscles is not as clearly defined as in the
hand
Extension (dorsiflexion)- EDL EDB EHL EHB
Flexion (plantarflexion)
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Deep peroneal nerve L5-S1
On attempts to dorsiflex the toes against resistance the tendons of the extensors digitorum and hallucis longus and the belly of the extensor digitorum brevis can be seen and palpated
DORSIFLEXION OF TOES
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
PRONATOR DRIFT (BARRErsquoS SIGN) In mild CST lesion with normal strength
Upper extremity outstretched to front palms up eyes closed hold for 20-30 seconds
Normally palm flatelbow straight if any deviation its similar bilaterally
Slight pronation without downward drift of the dominant arm (pseudodrift) is not abnormal
In mild CST lesion- pronation of hand flexion of the elbow (due to weakness of CST innervated muscles ie extensorssupinators abductors)
Similarly leg drift
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
With mild drift there is slight pronation of the hand and slight flexion of the elbow on the abnormal side With more severe drift there is more prominent pronation and obvious flexion of the elbow and there
may be downward drift of the entire arm
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Abnormal drift can occasionally occur with lesions elsewhere in the nervous system
Cerebellar disease may cause drift to some degree but the movement is outward and usually slightly upward
In parietal lobe lesions there may be ldquoupdriftrdquo with the involved arm rising overhead without the patientrsquos awareness
Other useful maneuvers include examination of forearm roll finger roll and rapid alternating movements
Thumb rolling was more sensitive (88) than pronator drift (47) forearm rolling (65) or index finger rolling (65)
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
UPDRIFT due to a parietal lobe lesion with loss of position sense
ARM ROLL- the involved extremity tends to have a lesser excursion abnormal extremity remain relatively fixed (lsquorsquopostedlsquorsquo)
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
REFLEXES
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
DTRMSR (MUSCLE STRETCH REFLEX) A reflex is an involuntary response to a sensory stimulus
When a normal muscle is passively stretched its fibres resist the stretch by contracting
Stretch reflex are important in maintaining erect posture
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
GRADES OF DTRS 0 = absent
1+ (or +) = present but diminished
2+ (or ++) = normal
3+ (or +++) = increased but not necessarily to a pathologic degree (fast normalunsustained clonus)
4+ (or ++++) = markedly hyperactive pathologic often with extrabeats or accompanying sustained clonus
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
bullA technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
bullTell the patient to pull just before you strike the tendon
REINFORCEMENT
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
bullThe patients arm should be partially flexed at the elbow with palm down
bull Place your thumb or finger firmly on the biceps tendon
Observe flexion at the elbow and watch for and feel the contraction of the biceps muscleEXAGGERATED- spread of reflexogenic areaaccompanying flexion of wrist fingers amp adduction of thumb
BICEPS REFLEX (C5C6)
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
The patient may be sitting or supine The arm is placed midway between flexion and extension and may be rested Strike the triceps tendon above its insertion to olecranon process
bullWatch for contraction of the triceps muscle and extension at the elbow
INVERTED TRICEPS JERKFlexion of elbow due to damage to afferent arc of triceps reflex
TRICEPS REFLEX (C6C7)
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
bullThe patients hand should rest on the abdomen or the lap with the forearm partly pronated
bullStrike the radius with the point or flat edge of the reflex hammer about 1 to 2 inches above the wrist
bullWatch for flexion of elbow with variable supination
bullEXAGGERATED associated flexion of wrist and fingers with adduction of forearm
bullINVERTED SUPINATOR REFLEX bullAfferent limb impaired
bullTwitch of the flexors of the hand and fingers without flexion and supination of the elbow
BRACHIORADIALIS SUPINATOR REFLEX (C5C6)
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
bullThe patient may be either sitting or lying down as long as the knee is flexed
bullBriskly tap the patellar tendon just below the patella
bullNote contraction of the quadriceps with extension at the knee
bullWESTPHAL SIGN - Absence of patellar reflex
bullINVERTED PATELLAR REFLEXbullTapping causes contraction of hamstrings and flexion of knee
bullLesion in efferent limb
KNEE REFLEX (L234)
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
bullIf the patient is sitting dorsiflex the foot at the ankle Persuade the patient to relax
bullStrike the Achilles tendon
bullWatch and feel for plantar flexion at the ankle Note also the speed of relaxation after muscular contraction
ANKLE REFLEX (PRIMARILY S1)
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
SUPERFICIAL SPINAL REFLEXESHow elicited
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
bullLightly but briskly stroke each side of the abdomen above (T8 T9 T10) and below (T10 T11 T12) the umbilicus
bullNote the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus
ABDOMINAL REFLEX
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
bullWith an object such as a key or the wooden end of an applicator stick
bullKnees must be extended
bullStroke the lateral aspect of the sole (S1 sural nerve sensory disribution ) from the heel to the ball of the foot at deliberate pace
bullUsually stopping at MTP joint
bullIf no response stimulus should continue along the metatarsal pad from the little toe medially stopping short of base of the great toeFar medial stimulation may actually elicit a plantar grasp response causing the toes to flex strongly
bullNote movement of the big toe normally plantar flexion with flexion of small toes
THE PLANTAR REFLEX (L5S1)
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
PATHOLOGICAL REFLEXES Pathologic reflexes are responses not generally found in the normal individual
Many are exaggerations and perversions of normal muscle stretch and superficial reflexes
-Spread of reflex results in the recruitment into the movement of muscles not normally involved classified as ldquoassociated movementsrdquo
Some are related to postural reflexes or primitive defence reflexes that are normally suppressed by cerebral inhibition
Responses normally seen in the immature nervous system of infancy then disappear only to reemerge later in the presence of disease
Most are seen in CST lesions frontal lobe disease
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
PATHOLOGICAL REFLEXES OF LOWER LIMBS More constant more easily elicited more reliable and more clinically relevant than
those in the upper limbs
Classified as
(a) those characterized in the main by dorsiflexion of the toes - Babinski
(b) those characterized by plantarflexion of the toes
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
BABINSKI SIGN Babinski reflex is part of primitive flexion reflex (withdrawl reflex) amp is normally
present in infancy
It is the pathological variant of the plantar reflex
Babinski response Instead of the normal flexor response dorsiflexion of the great toe precedes all other movement This is followed by spreading and extension of the other toes (fanningabduction) by marked dorsiflexion of the ankle and by flexion withdrawal of the hip and knee It is pathognomonic of an UMN lesion (TRIPLE FLEXION RESPONSE)
BRISSAUDrsquoS REFLEX- contraction of the tensor fascia lata causing slight internal rotation at the hip and more rarely abduction of the hip
The Brissaud reflex may be useful in the rare patient whose great toe is missing
The response may be bilateral and is then called the crossed flexor reflex
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
The Chaddock sign is elicited by stimulating the lateral aspect of the foot not the sole beginning about under the lateral malleolus near the junction of the dorsal and plantar skin drawing the stimulus from the heel forward to the small toe
It produces less withdrawal than plantar stimulation
Oppenheim sign is usually elicited by dragging the knuckles heavily down the anteromedial surface of the tibia from the infrapatellar region to the ankle
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Voluntary withdrawal rarely causes dorsiflexion of the ankle and there is usually plantar flexion of the toes (reflex vs voluntary withdrawl)
Occasionally withdrawal makes it impossible to be certain whether the toe was truly extensor or not (equivocal plantar responses)
Some patients have no elicitable plantar response in which case the plantars are said to be mute or silent
Toe extension may occasionally fail to occur because of disruption of the lower motor neuron innervation to the EHL (eg radiculopathy peroneal nerve palsy peripheral neuropathy amyotrophic lateral sclerosis [ALS])
With pes cavus and high-arched feet the response is difficult to evaluate because of fixed dorsiflexion of the toe
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
PATHOLOGICAL REFLEX OF UPPER EXTREMITIES They are less constant more difficult to elicit and usually less significant
diagnostically than those found in the lower extremities
They primarily fall into two categories
- FRSs
-exaggerations of or variations on the finger flexor reflex- These responses occur only with lesions above the C5 or C6 segment of the cervical spinal cord
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
FRONTAL RELEASE SIGNS Normally present after birth and in infancy disappear after the maturation of CST
GRASPFORCED GRASPING REFLEX- stimulation of skin of palmar surface between thumb amp forefinger leads to involuntary flexor response of the fingers and hand
PALMOMENTAL REFLEX- contraction of the mentalis and orbicularis oris muscles causing wrinkling of the skin of the chin with slight retraction in response to scratching or stroking the palm of the ipsilateral hand (thenar eminence)
SNOUT- is puckering and protrusion of the lips in response to pressing firmly backward on the philtrum of the upper lip
SUCK- stimulation of the perioral region is followed by sucking movements of the lips tongue and jaw
ROOTING- when the lips mouth and even head deviate toward a tactile stimulus delivered beside the mouthcheek
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
HOFFMANN amp TROMNER SIGN (Pathological Wartenberg)Wrist dorsiflexed fingers partially flexed hold partially extended middle finger and give fick to nail of middle fingerResponse- flexion amp adduction of the thumb with flexion of index finger sometimes flexion of other fingers as well
Click icon to add picture
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
CLONUS Clonus is a series of rhythmic involuntary muscular contractions induced by the
sudden passive stretching of a muscle or tendon
Occurs at ankle knee wrist
Unsustained (transient exhaustible or abortive) symmetric ankle clonus may occur in normal individuals with physiologically fast DTRs
Sustained clonus is never normal
MECHANISM- alternating stretch reflexes (muscle spindle Golgi tendon agonistantagonist)
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
Knee ankle moderate flexion quick dorsiflexion and maintain slight pressureResponse- rhythmic alternating flexions and extensions of the ankle
PATELLAR- leg extended relaxedDownward thrust rhythmic up-down movements
WRISTFINGERS- sudden passive extension of wrist or fingers
ANKLE CLONUS
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
ABNORMAL MOVEMENTS
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
EXAMINATIONbull Observe casually during history
ndash Any involuntary movements and their distribution
ndash Blink frequency
ndash Excessive sighing
bull Cognitive assessment
orthostatic hypotension
bull Gait
bull Eye movement (range amp speed)
bull Tone power coordination plantars
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
OBSERVATIONbull Rhythmic vs arrhythmic
bull Sustained vs nonsustained
bull Paroxysmal vs Nonparoxysmal
bull Slow vs fast
bull Amplitude
At rest vs action
bull Patterned vs non-patterned
bull Combination of varieties of movements
Supressibility
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
RHYTHMIC
bull Tremor
bull Dystonic tremor
bull Dystonic myorhythmia
bull Myoclonus (segmental)
bull Myoclonus (oscillatory)
bull Moving toesfingers
bull Periodic movements of sleep
bull Tardive dyskinesia
ARRTHYMIC
bull Akathitic movements
bull Athetosis
bull Ballism
bull Chorea
bull Dystonia
bull Hemifacial spasm
bull Hyperekplexia
bull Arrhythmic myoclonus
bull Tics
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
PAROXYSOMAL
bull Tics
bull PKD
bull Sterotypies
bull Akathic movements
bull Moving toes
bull Myorhythmia
CONTIGOUS
bull Abdominal dyskinesias
bull Athetosis
bull Tremors
bull Dystonic postures
bull Myoclonus rhythmic
bull Myokymia
bull Tic status
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
TREMORS
bull An oscillatory typically rhythmic and regular movement that affects one or more body parts
bull Produced by rhythmic alternating or simultaneous contractions of agonists and antagonists
bull Distinction between rest postural action or with intention or task specific
Better appreciated by placing a sheet of paper on the outstreched finger
Alcoholnicotinecaffeineamphetamines ephedrineEnhanced PT- hyperthyroidism
ASTERIXIS (NEGATIVE MYOCLONUS) Inability to sustain normal muscle toneIn metabolic encephalopathy hepaticThe lapse in postural tone may cause the hands to suddenly flop downward then quickly recover causing a slow and irregular flapping motionFOOTFLAP- inability to keep the foot dorsiflexedUnilateral asterixis occur in focal brain lesion involving contralateral thalamus
TICSQuick irregular but repetitive movementsUNVOLUNTARY- abnormal movement the patient has some degree of awareness amp movement is in response to the urge of some compelling inner force akathisia restlessleg
HEMIFACIAL SPASM (HFS)Involuntary twitching contraction of the facial muscles on one side of the faceInjury to facial nerve tumor or blood vessel compressing the facial nerve bells palsy
Stimulation of facial nerve causing it to misfire making facial muscle contraction MC cause AICA compressing at the origin in brainstem
CHOREA (GR DANCE)
characterized by involuntary irregular purposeless random and nonrhythmic hyperkinesiasmovements are spontaneous abrupt brief rapid jerky and unsustainedIndividual movements are discrete but they are variable in type and location causing an irregular pattern of chaotic multiform constantly changing movements that seem to flow from one body part to anotherPresent at rest increase with activityemotionOne extremity hemichorea generalisedPiano playing movements MILKMAID GRIPMOTOR IMPERSISTENCE
ATHETOSIS (WITHOUT FIXED POSITION)Slower more sustained and larger in amplitude than those in choreaInvoluntary irregular coarse somewhat rhythmic and writhing or squirming in character
Characterized by any combination of flexion extension abduction pronation and supination often alternating and in varying degreesAthetosis ndash chorea overlap
DYSTONIA
Spontaneous involuntary sustained muscle contractions that force the affected parts of the body into abnormal movements or postures sometimes with contraction of agonists and antagonists
HEMIBALISMUSWild flinging ballistic movements (rapid amp forceful) usually unilateralCan be BIBALLISMUSPARABALLISMUSMONOBALLISMUSLesions in contralateral basal ganglia (subthalamic nuclei)Disinhibition of the motor thalamus and the cortexSevere hemichorea vs hemiballismus
FASICULATIONS
Fasciculations are fine rapid flickering or vermicular twitching movements due to contraction of a bundle or fasciculus of muscle fibresSeen in MND other LMN lesions- radiculopathy peripheral neuropathy chronic deenervating process
Also seen by the administration of cholinergic drugs (egpyridostigmine)
COORDINATION
CLINICAL MANIFESTATION OF CEREBELLAR DYSFUNCTION Dyssynergia- decomposition of movements
Dysmetria- hypermetria hypometria- past ponting
Agonist ndash Antagonist incoordination ndash dysdiadochokinesia loss of checking movements rebound phenomenon
Tremor ndash intention tremors
Hypotonia ndash pendular knee jerks
Dysarthria ndash scanning speech
Nystagmus
Posture amp gait- deviation swaying broad based gait
FINGERndashTO-NOSE TEST FINGER-NOSE-FINGER TESTTHINGS TO LOOK FOR- INTENTION TREMOR DYSMETRIA DYSSYNERGIA ATAXIA
Click icon to add picture
the patient is asked to place the heel of one foot on the opposite knee tap it up and down on the knee several times push the point of the heel (not the instep) along the shin in a straight line to the great toe and then bring it back to the knee
The patient with cerebellar disease is likely to raise the foot too high flex the knee too much and place the heel down above the kneeThe excursions along the shin are jerky and unsteady
SENSORY ATAXIA- difficulty locating the knee with the heel groping around for it there is difficulty keeping the heel on the shin and it may slip off to either side while sliding down the shin
HEEL- SHIN TEST
RAPIDLY ALTERNATING MOVEMENTS Patient is asked to alternatively supinate amp pronate his hands alternate opening amp
closing of fist touching tip of his thumb with the tip of each finger rapidly in sequence
Any movement involving reciprocal innervation and alternate action of agonists and antagonists can be used
Due to impairment of the reciprocal relationship between agonist and antagonist one movement cannot be followed quickly by its opposite movements
IMPAIRED CHECK amp REBOUND PHENOMENON Impairment of the reciprocal relationship between agonist and antagonist
Absence of REBOUND PHENOMENON IMPAIRED CHECKING is seen
DEVIATION amp PAST POINTING In labyrinthine disease or with a cerebellar hemispheric lesion the arm will deviate
to the involved side on the return track more so with the eyes closed
This deviation is called PAST PONTING
The pattern of deviation is different in vestibular as opposed to cerebellar past pointing
In vestibular disease past pointing occurs with both upper extremities toward the involved side in unilateral cerebellar disease past pointing occurs toward the side of the lesion but only in the ipsilateral arm
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
CLINICAL MANIFESTATION OF CEREBELLAR DYSFUNCTION Dyssynergia- decomposition of movements
Dysmetria- hypermetria hypometria- past ponting
Agonist ndash Antagonist incoordination ndash dysdiadochokinesia loss of checking movements rebound phenomenon
Tremor ndash intention tremors
Hypotonia ndash pendular knee jerks
Dysarthria ndash scanning speech
Nystagmus
Posture amp gait- deviation swaying broad based gait
FINGERndashTO-NOSE TEST FINGER-NOSE-FINGER TESTTHINGS TO LOOK FOR- INTENTION TREMOR DYSMETRIA DYSSYNERGIA ATAXIA
Click icon to add picture
the patient is asked to place the heel of one foot on the opposite knee tap it up and down on the knee several times push the point of the heel (not the instep) along the shin in a straight line to the great toe and then bring it back to the knee
The patient with cerebellar disease is likely to raise the foot too high flex the knee too much and place the heel down above the kneeThe excursions along the shin are jerky and unsteady
SENSORY ATAXIA- difficulty locating the knee with the heel groping around for it there is difficulty keeping the heel on the shin and it may slip off to either side while sliding down the shin
HEEL- SHIN TEST
RAPIDLY ALTERNATING MOVEMENTS Patient is asked to alternatively supinate amp pronate his hands alternate opening amp
closing of fist touching tip of his thumb with the tip of each finger rapidly in sequence
Any movement involving reciprocal innervation and alternate action of agonists and antagonists can be used
Due to impairment of the reciprocal relationship between agonist and antagonist one movement cannot be followed quickly by its opposite movements
IMPAIRED CHECK amp REBOUND PHENOMENON Impairment of the reciprocal relationship between agonist and antagonist
Absence of REBOUND PHENOMENON IMPAIRED CHECKING is seen
DEVIATION amp PAST POINTING In labyrinthine disease or with a cerebellar hemispheric lesion the arm will deviate
to the involved side on the return track more so with the eyes closed
This deviation is called PAST PONTING
The pattern of deviation is different in vestibular as opposed to cerebellar past pointing
In vestibular disease past pointing occurs with both upper extremities toward the involved side in unilateral cerebellar disease past pointing occurs toward the side of the lesion but only in the ipsilateral arm
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
FINGERndashTO-NOSE TEST FINGER-NOSE-FINGER TESTTHINGS TO LOOK FOR- INTENTION TREMOR DYSMETRIA DYSSYNERGIA ATAXIA
Click icon to add picture
the patient is asked to place the heel of one foot on the opposite knee tap it up and down on the knee several times push the point of the heel (not the instep) along the shin in a straight line to the great toe and then bring it back to the knee
The patient with cerebellar disease is likely to raise the foot too high flex the knee too much and place the heel down above the kneeThe excursions along the shin are jerky and unsteady
SENSORY ATAXIA- difficulty locating the knee with the heel groping around for it there is difficulty keeping the heel on the shin and it may slip off to either side while sliding down the shin
HEEL- SHIN TEST
RAPIDLY ALTERNATING MOVEMENTS Patient is asked to alternatively supinate amp pronate his hands alternate opening amp
closing of fist touching tip of his thumb with the tip of each finger rapidly in sequence
Any movement involving reciprocal innervation and alternate action of agonists and antagonists can be used
Due to impairment of the reciprocal relationship between agonist and antagonist one movement cannot be followed quickly by its opposite movements
IMPAIRED CHECK amp REBOUND PHENOMENON Impairment of the reciprocal relationship between agonist and antagonist
Absence of REBOUND PHENOMENON IMPAIRED CHECKING is seen
DEVIATION amp PAST POINTING In labyrinthine disease or with a cerebellar hemispheric lesion the arm will deviate
to the involved side on the return track more so with the eyes closed
This deviation is called PAST PONTING
The pattern of deviation is different in vestibular as opposed to cerebellar past pointing
In vestibular disease past pointing occurs with both upper extremities toward the involved side in unilateral cerebellar disease past pointing occurs toward the side of the lesion but only in the ipsilateral arm
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
the patient is asked to place the heel of one foot on the opposite knee tap it up and down on the knee several times push the point of the heel (not the instep) along the shin in a straight line to the great toe and then bring it back to the knee
The patient with cerebellar disease is likely to raise the foot too high flex the knee too much and place the heel down above the kneeThe excursions along the shin are jerky and unsteady
SENSORY ATAXIA- difficulty locating the knee with the heel groping around for it there is difficulty keeping the heel on the shin and it may slip off to either side while sliding down the shin
HEEL- SHIN TEST
RAPIDLY ALTERNATING MOVEMENTS Patient is asked to alternatively supinate amp pronate his hands alternate opening amp
closing of fist touching tip of his thumb with the tip of each finger rapidly in sequence
Any movement involving reciprocal innervation and alternate action of agonists and antagonists can be used
Due to impairment of the reciprocal relationship between agonist and antagonist one movement cannot be followed quickly by its opposite movements
IMPAIRED CHECK amp REBOUND PHENOMENON Impairment of the reciprocal relationship between agonist and antagonist
Absence of REBOUND PHENOMENON IMPAIRED CHECKING is seen
DEVIATION amp PAST POINTING In labyrinthine disease or with a cerebellar hemispheric lesion the arm will deviate
to the involved side on the return track more so with the eyes closed
This deviation is called PAST PONTING
The pattern of deviation is different in vestibular as opposed to cerebellar past pointing
In vestibular disease past pointing occurs with both upper extremities toward the involved side in unilateral cerebellar disease past pointing occurs toward the side of the lesion but only in the ipsilateral arm
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
RAPIDLY ALTERNATING MOVEMENTS Patient is asked to alternatively supinate amp pronate his hands alternate opening amp
closing of fist touching tip of his thumb with the tip of each finger rapidly in sequence
Any movement involving reciprocal innervation and alternate action of agonists and antagonists can be used
Due to impairment of the reciprocal relationship between agonist and antagonist one movement cannot be followed quickly by its opposite movements
IMPAIRED CHECK amp REBOUND PHENOMENON Impairment of the reciprocal relationship between agonist and antagonist
Absence of REBOUND PHENOMENON IMPAIRED CHECKING is seen
DEVIATION amp PAST POINTING In labyrinthine disease or with a cerebellar hemispheric lesion the arm will deviate
to the involved side on the return track more so with the eyes closed
This deviation is called PAST PONTING
The pattern of deviation is different in vestibular as opposed to cerebellar past pointing
In vestibular disease past pointing occurs with both upper extremities toward the involved side in unilateral cerebellar disease past pointing occurs toward the side of the lesion but only in the ipsilateral arm
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
IMPAIRED CHECK amp REBOUND PHENOMENON Impairment of the reciprocal relationship between agonist and antagonist
Absence of REBOUND PHENOMENON IMPAIRED CHECKING is seen
DEVIATION amp PAST POINTING In labyrinthine disease or with a cerebellar hemispheric lesion the arm will deviate
to the involved side on the return track more so with the eyes closed
This deviation is called PAST PONTING
The pattern of deviation is different in vestibular as opposed to cerebellar past pointing
In vestibular disease past pointing occurs with both upper extremities toward the involved side in unilateral cerebellar disease past pointing occurs toward the side of the lesion but only in the ipsilateral arm
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
DEVIATION amp PAST POINTING In labyrinthine disease or with a cerebellar hemispheric lesion the arm will deviate
to the involved side on the return track more so with the eyes closed
This deviation is called PAST PONTING
The pattern of deviation is different in vestibular as opposed to cerebellar past pointing
In vestibular disease past pointing occurs with both upper extremities toward the involved side in unilateral cerebellar disease past pointing occurs toward the side of the lesion but only in the ipsilateral arm
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
CEREBELLAR DRIFT Cerebellar lesion may also cause a drift of the outstretched upper extremities
With cerebellar drift the arm drifts mainly outward either at the same level rising or less often sinking
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
STATION amp GAIT
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
ROMBERG SIGN When proprioception is disturbed the patient may be able to stand with eyes open
but sways or falls with eyes closed
The Romberg sign is used primarily as a test of proprioceptive not cerebellar function
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
EXAMINATION OF GAIT Width of gait- normal 2 inches between two medial malleoli during the stride phase
Forefoot clearance
Stride length- short in extrapyramidal disease
Movement of hip- excessive-myopathy tilting- trendelenburg
Tandem walking
Turning
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
HEMIPLEGIC GAIT
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
FESTINATING GAIT
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
CEREBELLAR ATAXIC GAIT
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
STAMPING STOMPING GAIT
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
DIPLEGIC CEREBRAL PALSY GAIT
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
MYOPATHIC WADDLING GAIT
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
STEEEPAGE GAIT
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-
- Examination of the motor system
- Why do we do a motor system examination
- outline
- anatomy
- Slide 5
- Organization of motor system
- Corticospinal and corticobulbar
- Slide 8
- Extrapyramidal system
- Basal ganglia
- Slide 11
- Slide 12
- Functions of basal ganglia
- Neuromuscular unit
- Muscle volume amp contour
- Slide 16
- Slide 17
- Slide 18
- Muscle tone
- Muscle tone (2)
- Examination of tone
- Slide 22
- Slide 23
- MOTOR STRENGTH AND POWER
- Slide 25
- Slide 26
- Misleads
- Slide 28
- STRENGTH scales
- Slide 30
- Pattern of weakness
- Slide 32
- Nonorganic weakness
- UMN vs lmn
- Muscles of the neck
- Slide 36
- Slide 37
- Slide 38
- Slide 39
- Slide 40
- The sCAPULA
- rhomboids
- trapezius
- SERRATIUS ANTERIOR
- Winging of scapula
- Swan dive posture
- THE GLENOHUMERAL JOINT
- supraspinatus
- deltoid
- Pectoralis major
- Lattismus dorsi
- The elbow
- Biceps brachii
- brachioradialis
- Triceps
- Slide 56
- The wrist
- Slide 58
- fingers
- Finger flexors
- Slide 61
- Thumb muscle
- Slide 63
- Slide 64
- Slide 65
- Muscles of abdomen
- ABDOMINAL MUSCLES
- The hip joint
- Slide 69
- Slide 70
- Flexors of thigh
- Extensors of thigh
- Abduction of thigh at hip
- Slide 74
- Adductors of thigh at the hip
- Internalmedial rotation
- The knee joint
- Flexion at the knee
- Extension at knee
- Slide 80
- The ankle joint
- Plantarflexion of the foot
- Dersiflexion extension of the foot
- Inversion of the foot
- Eversion of the foot
- Muscles of foot amp toes
- Dorsiflexion of toes
- Pronator drift (barrersquos sign)
- Slide 89
- Slide 90
- Slide 91
- reflexes
- DTRMSR (muscle stretch reflex)
- Grades of dtrs
- reinforcement
- Biceps reflex (c5c6)
- Triceps reflex (c6c7)
- Brachioradialis supinator reflex (C5C6)
- Knee reflex (l234)
- Slide 100
- Ankle reflex (primarily s1)
- Slide 102
- Superficial spinal reflexes
- Abdominal reflex
- The plantar reflex (L5S1)
- PATHOLOGICAL REFLEXES
- Pathological reflexes of lower limbs
- BABINSKI SIGN
- Slide 109
- Slide 110
- Slide 111
- Pathological reflex of upper extremities
- Frontal release signs
- Hoffmann amp tromner sign (Pathological Wartenberg)
- clonus
- Ankle clonus
- Abnormal movements
- Slide 118
- examination
- observation
- Slide 121
- Slide 122
- tremors
- Asterixis (Negative myoclonus)
- tics
- Hemifacial spasm (HFS)
- Chorea (gr dance)
- Athetosis (without fixed position)
- dystonia
- hemibalismus
- FASICULATIONS
- coordination
- Clinical manifestation of cerebellar dysfunction
- fingerndashto-nose test finger-nose-finger test
- Heel- shin test
- Rapidly alternating movements
- Impaired check amp rebound phenomenon
- Deviation amp past pointing
- Cerebellar drift
- Station amp gait
- Romberg sign
- Examination of gait
- Hemiplegic gait
- Festinating gait
- Cerebellar ataxic gait
- Stamping stomping gait
- Diplegic cerebral palsy gait
- Myopathic waddling gait
- Steeepage gait
- Slide 150
-