,motor examination

MOTOR SYSTEM MOTOR SYSTEM

EXAMINATIONEXAMINATION (Strength )(Strength )

Moderator – Dr. V.K. GOELModerator – Dr. V.K. GOEL

Presenter- Dr. Harmeet RiyaitPresenter- Dr. Harmeet Riyait

QUICK ASSESSMENT – 1. Patient working

2. Standing up from lying & sitting position

3. Dressing or undressing

4. Lightly jumping or hopping

STRENGTH OF INDIVIDUAL MUSCLES

Q.1. Is the muscle as strong as might be expected (bearing in mind the build & age of both patient & examiner)?

Q.2. Is it as strong as same muscle on other side? Q.3. What is the degree of weakness if any? Q.4. Is the weakness constant or variable?-does it

improve on rest or on encouragement? Q.5. Is there any painful condition? Q.6. Are the actions the patients is known to be

able to carry out compatible with any apparent weakness demostrated?

Quantitative assessment of weakness

5. Normal power

4. The muscle, though able to make its full normal movement, is overcome by resistance.

3. The muscle is able to make its normal movement against gravity, but not against

additional resistance.

2. The muscle can only make, its normal movement when the limb is so positioned

that gravity is eliminated.

1. There is a visible or palpable flicker of contraction, but no resultant movement of

limb or joint.

0. Total paralysis.

Note –4+ against strong resistance

4 against moderate resistance

4- against mild resistance

SEGMENTAL NERVE SUPPLYSEGMENTAL NERVE SUPPLY PERIPHERAL NERVE SUPPLYPERIPHERAL NERVE SUPPLY ACTION OF THE MUSCLEACTION OF THE MUSCLE METHOD OF TESTING - EXPOSEDMETHOD OF TESTING - EXPOSED

- POSITION- POSITION

- PALPATE - PALPATE

- COMPARE - COMPARE

SUPRA SPINATUS

Main Segmental Supply – C5

Peripheral Nerve – Suprascapular

Test – The patient tries to initiate abduction of the arm from the side against resistance

DELTOID

Main Segmental Supply - C5

Peripheral Nerve – Circumflex

Test – Ask the patient to abducted from 30º to 60º the arm against examiner resistance

INFRA SPINATUS

Mains Segmental Supply – C5

Peripheral Nerve – Suprascapular

Test – The patient flexes his elbow, holds the elbow to his side and then attempts to turn the fore arm backwards against resistance

SERRATUS ANTERIORMain Seg supply C5C6C7 P. Nerve – N. to serratus anterior

TestPush the wall by

his hands keeping elbow extended

If seratous anterior is weak, scapular

medial borden will become prominent

– winging of scapula

PECTORALIS MAJOR

Main Seg supply C5C6C7 P. Nerve – Lat. & medial pectoral N.

Test-1Placing the hand

on hip and pressing in wards

Test-2 Strech the arm out infront & than to clasp the hands together while

examiner endeavour to hold

them apart

LATISSIMUS DORSI

Main Seg supply C7 P. Nerve –Nerve to L. Dorsi

Test-1

While palpating the

muscle, ask the

patient to cough

Test-2

Resist the patient’s

attempt to adduct

the arm when

abducted to above

90º

RHOMBOIDSRHOMBOIDS

SEGMENTAL SUPPLY C5SEGMENTAL SUPPLY C5 PERIPHERAL NERVE NV TO PERIPHERAL NERVE NV TO

RHOMBOIDSRHOMBOIDS METHOD ASK THE PATIENT TO METHOD ASK THE PATIENT TO

PLACE HIS HANDS ON HIP AND PLACE HIS HANDS ON HIP AND TRY TO FORCE HIS ELBOW TRY TO FORCE HIS ELBOW BACKWARDS.BACKWARDS.

TrapeziusTrapezius

Spinal accessory Spinal accessory nervenerve

Upper part-ask the Upper part-ask the patient to shrug his patient to shrug his shoulders while you shoulders while you try to press them try to press them from behind.from behind.

Lower part – ask the Lower part – ask the patient to patient to approximate his approximate his shoulder blades.shoulder blades.

MUSCLES OF ELBOW JOINT

BICEPS

Main Segmental Supply –C5

Peripheral N. – Musculo cutaneous

Test – Pt. flexes his elbow against resistance, the forearm being supinated

BRACHIORADIALIS

Main Segmental Supply-C5C6

Peripheral Nerve – Radial

Test – Pt. pronates the forearm and draws the thumb towards the nose against resistance

TRICEPS



Test – Pt. attempts to extend the elbow against resistance

MUSCLES OF FOREARM & WRIST JOINT

EXTENSOR CARPI RADIALIS LONGUS

Main Segmental Supply –C6C7

Peripheral N. – Radial

Test – Pt. holds the fingers partialy extended and dorsiflexes the wrist towards the radial side against resistance

EXTENSOR DIGITORUM

Main Segmental Supply-C7


Test – Examiner attempt to flex the patients extended fingers at metacarpophalangeal joints

FLEXOR CARPI RADIALS

Mains Segmental Supply – C6C7

Peripheral Nerve – Median

Test – Examiner resist the patient attempt to flex the wrist towards the radial side

FLEXOR CARPI ULNARIS

Mains Segmental Supply – C8 Peripheral Nerve - Ulnar

MUSCLES OF THUMB

ABDUCTOR POLLICIS LONGUS


Peripheral N. – Radial

Test – Pt. attempts to maintain his thumb in abduction against the examiner resistance

EXTENSOR POLLICIS BREVIS



Test – Pt. attempts to extend the thumb while the examiner attempts to flex it at MCP joint

EXTENSOR POLLICIS LONGUS



Test – Patients attempt to extend the thumb while the examiner attempts to flex it at the interphalangeal joint

OPPONENS POLLICIS

Main Segmental Supply –T1

Peripheral N. – Median

Test – Pt. attempts to touch the little finger with the thumb

ABDUCTOR POLLICIS BREVIS

Main Segmental Supply - T1


Test – Ask the patient to abduct the thumb in a plane at right angle to the palmar aspect of index finger against the resistance of examiner thumb

FLEXOR POLLICIS LONGUS



Test – Patient attempt to flex the distal phalanx of the thumb against the patient resistance (Hold the proximal phalanx)

Adductor pollicisAdductor pollicis

T1T1 ULNAR NERVEULNAR NERVE The patient attempts to hold a piece The patient attempts to hold a piece

of paper between the thumb and the of paper between the thumb and the palmar aspect of forefinger.palmar aspect of forefinger.

MUSCLES OF HAND & FINGERS

LUMBRICAL & INTEROSSI

Main Seg supply C8 T1

Median – Lumbical I & IIUlnar – lumbrical III & IV & interossi

A. Lumbricals – Pt. Tries to flex the

extended fingers at the MCP Joints

B. Interossi – Pt. attemps to keep the

fingers abducted against resistance

IST DORSAL INTEROSSI & IST PALMAR INTROSSI

Main Seg supply T1

Peripheral nerve ulnar

Pt. Tries to abduct the fore finger against

resistance

Pt. Tries to Adduct the fore finger against

resistance

FLEXOR DIGITORUM SUBLIMIS


Peripheral N. – Median

Test – Pt. flexes the finger at the proximal inter phalangel joint against resistance (examiners fingers placed on middle phalanx)

FLEXOR DIGITORUM PROFUNDUS


P. N. – Median Ist & IInd Ulnar IIIrd & IVth

Test – Pt. Flexes the terminal phalanx of the fingers against resistance, the middle phalanx being supported

ABDUCTOR DIGITI MINIMI

Mains Segmental Supply – T1

P. N. – Ulnar

Test – Back of hand is placed on the table & little finger abducted against resistance (sign of ulnar N. lesion)

Muscles of the TRUNKMuscles of the TRUNK

EXTENSORS OF THE SPINEEXTENSORS OF THE SPINE SUPPLIED BY ALL SEGMENTSSUPPLIED BY ALL SEGMENTS

THROUGH POSTERIOR RAMI OF THROUGH POSTERIOR RAMI OF SPINAL NERVESSPINAL NERVES

TEST– The patient lies on his face and TEST– The patient lies on his face and then attempts to raise his shoulders then attempts to raise his shoulders off the bed.off the bed.

IntercostalsIntercostals

T1-T12 Through intercostal nervesT1-T12 Through intercostal nerves Observe the movements of the ribs Observe the movements of the ribs

on expiration and inspiration and the on expiration and inspiration and the movements of the muscles in the movements of the muscles in the intercostal spaces.intercostal spaces.

Abdominal musclesAbdominal muscles

T5- L1 T5- L1 Intercostal, ilioinguinal and iliohypogastric Intercostal, ilioinguinal and iliohypogastric

nervesnerves The patient lies on his back and attempts to The patient lies on his back and attempts to

raise his head against light resistence. raise his head against light resistence. Watch movement of the umbilicus.Watch movement of the umbilicus.

Beevor’s signBeevor’s sign -with paralysis of the lower -with paralysis of the lower segment the umbilicus moves upwards but segment the umbilicus moves upwards but when upper segment is affected, umbilicus when upper segment is affected, umbilicus is pulled downwards.is pulled downwards.

Ask the patient to sit up in bed from the Ask the patient to sit up in bed from the supine position without the aid of arms.supine position without the aid of arms.

Inability to do so indicates severe Inability to do so indicates severe weakness of the muscles of abdomen weakness of the muscles of abdomen and the hip flexors.and the hip flexors.

Babinski’s rising up signBabinski’s rising up sign –in spastic –in spastic paralysis of the leg the affected limb paralysis of the leg the affected limb will rise first, but in hysterical paralysis will rise first, but in hysterical paralysis this does not occur.this does not occur.

DiaphragmDiaphragm

C3,4,5 Phrenic nerveC3,4,5 Phrenic nerve Simple bedside test- ask the patient Simple bedside test- ask the patient

to take a deep breath and to count to take a deep breath and to count slowly. Most people can easily get to slowly. Most people can easily get to 20 or more with a single breath.20 or more with a single breath.

Inability of the patient to breathe Inability of the patient to breathe easily when lying flateasily when lying flat sometimes sometimes presents as difficulty sleeping. presents as difficulty sleeping.

Hip flexionHip flexion

L2L3 nerve roots --the femoral nerve L2L3 nerve roots --the femoral nerve ask the patient to lie down and raise ask the patient to lie down and raise

each leg separately while the each leg separately while the examiner resists. examiner resists.

. This tests the iliopsoas muscles . This tests the iliopsoas muscles

Hip extensionHip extension

instruct the patient to instruct the patient to press down on the press down on the examiner's hand examiner's hand which is placed which is placed underneath the underneath the patient's thigh. This patient's thigh. This tests the gluteus tests the gluteus maximus maximus

Inferior gluteal nerve Inferior gluteal nerve [l4,L5][l4,L5]

Observe the pt Observe the pt standing from a low standing from a low chairchair

Hip adductionHip adduction

place your hands place your hands on the inner thighs on the inner thighs of the patient and of the patient and asking them to asking them to bring both legs bring both legs together. This tests together. This tests the adductors of the adductors of the medial thigh. the medial thigh. the L2, L3 and L4 the L2, L3 and L4 nerve roots. nerve roots.

Hip abductionHip abduction

place your hands on place your hands on the outer thighs and the outer thighs and asking the patient to asking the patient to move their legs apart. move their legs apart. This tests the gluteus This tests the gluteus maximus and gluteus maximus and gluteus minimus. minimus.

Abduction of the hip Abduction of the hip is mediated by the is mediated by the L4, L5 and S1 nerve L4, L5 and S1 nerve roots. roots.

Knee flexionKnee flexion

hold the knee from the hold the knee from the side and applying side and applying resistance under the resistance under the ankle and instructing ankle and instructing the patient to pull the the patient to pull the lower leg towards lower leg towards their buttock as hard their buttock as hard as possible. This tests as possible. This tests the hamstrings. L5 the hamstrings. L5 and S1 nerve roots and S1 nerve roots via the sciatic nerve. via the sciatic nerve.

Knee extensionKnee extension place one hand under place one hand under

the knee and the the knee and the other on top of the other on top of the lower leg to provide lower leg to provide resistance. Ask the resistance. Ask the patient to "kick out" patient to "kick out" or extend the lower or extend the lower leg at the knee.This leg at the knee.This tests the quadriceps tests the quadriceps muscle. muscle.

L3 and L4 nerve roots L3 and L4 nerve roots via the femoral nerve. via the femoral nerve.

Ankle dorsiflexionAnkle dorsiflexion Hold the top of the ankle and have the Hold the top of the ankle and have the

patient pull their foot up towards their patient pull their foot up towards their face as hard as possible.This tests the face as hard as possible.This tests the muscles in the anterior compartment muscles in the anterior compartment of the lower leg. of the lower leg. L4 and L5 nerve roots via the L4 and L5 nerve roots via the peroneal nerve peroneal nerve

Ask the patient to walk on heelsAsk the patient to walk on heels

Ankle plantarflexionAnkle plantarflexion Holding the bottom of Holding the bottom of

the foot, ask the patient the foot, ask the patient to "press down on the to "press down on the gas pedal" as hard as gas pedal" as hard as possible. This tests the possible. This tests the gastrocnemius and gastrocnemius and soleus musclessoleus muscles

S1 and S2 nerve roots S1 and S2 nerve roots via the tibial nerve. via the tibial nerve.

Ask the patient to walk Ask the patient to walk on toeson toes

Extension of great toeExtension of great toe

Ask the patient to Ask the patient to move the large toe move the large toe against the against the examiner's examiner's resistance "up resistance "up towards the towards the patient's face". The patient's face". The EHL muscle is EHL muscle is almost completely almost completely innervated by the innervated by the L5 nerve root.L5 nerve root.

Summary- upper Summary- upper limblimb

ROOTROOT MOVEMENTSMOVEMENTS REFLEXREFLEX

C5C5 Shoulder Shoulder abduction, elbow abduction, elbow flexionflexion

BicepsBiceps

C6C6 Elbow flexion Elbow flexion (semipronated)(semipronated)

supinatorsupinator

C7C7 Finger extension, Finger extension, elbow extensionelbow extension

TricepsTriceps

C8C8 Finger flexorsFinger flexors

T1T1 Small ms of Small ms of hand.hand.

Pronator testPronator test Ask the patient to hold his arms out in Ask the patient to hold his arms out in

front with his palms facing upwards and front with his palms facing upwards and to close his eyes tightly.to close his eyes tightly.

One arm pronates and drifts downwards One arm pronates and drifts downwards indicates indicates weakness on that sideweakness on that side..

Both arms drift downwardsBoth arms drift downwardsb/l weaknessb/l weakness Arm risesArm risescerebellar diseasecerebellar disease Fingers continuously move up and down Fingers continuously move up and down

(pseudoathetosis)-(pseudoathetosis)-deficit of joint position deficit of joint position sensesense..

Lower limbLower limb

RootRoot MovementMovement ReflexReflex

L1, L2 L1, L2 Hip flexionHip flexion

L3, L4L3, L4 Knee extensionKnee extension Knee reflexKnee reflex

L5L5 Dorsiflexion of foot, Dorsiflexion of foot, inv & eversion of inv & eversion of ankle, extn of great ankle, extn of great toe.toe.

S1S1 Hip extension, knee Hip extension, knee flexion, plantar flexion, plantar flexion.flexion.

Ankle reflexAnkle reflex

,motor examination

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