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Nickie Ricobear Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope

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OUTLINE {

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I. Introduction
II. Motor Examination Upper Motor Neurons (UMNs)
A. Inpection  part of the Central Nervous System (CNS)
0. Palpation  composed of neurons whose cells bodies are located in the brain
C. Muscle Synmmetry and 0ulk or spinal cord
D. Muscle Tone
E. Manual Motor Testing Lower Motor Neurons (LMNs)
1. Major Muscle Groups
 parrt of the Peripheral Nervous System (PNS)
2. Intrinsic Muscle of Hand
 made up of motor and sensory neurons with cell bodies located
3. Flexor of Fingers
4. Wrist Flexion outside of the brain and spinal cord
5. Wrist Extension
6. Elbow Flexion a PNS travel to and from the periphery, connecting the organs of action
7. Elbow Extension with the CNS.
8. Shoulder adduction
9. Shoulder abduction Efferents
10. Hip Flexion
 Nerves which carry impulses away from the CNS
11. Hip Extension
12. Hip Abduction
13. Hip Adduction Afferents
14. Knee Extension  bring signals towards the CNS
15. Knee Flexion
16. Ankle dorsiflexion Spinal nerve roots
17. Ankle plantar flexion  bundles of axons that contain both afferent and efferent nerves
III. Assessment which enter and exit the spinal cord at any given level and
A. Muscle Strength Grading
generally connect to the same distal anatomic area
0. Alternative Grading
C. Pathologic Finding
D. Peripheral nerves Neuroforamina
IV. Gait Testing  paired openings that allow for their passage out of the bony
A. Station Testing protection provided by the vertebral column where the nerve roots
0. Cerebellar / Coordination Testing exit/enter the spinal cord

Transmission of Signals from the Motor Cortex to the Muscles:

a. Voluntary movement begins withan impulse generated by the cell

bodies in the cortex
b. Motor signals are transmitted directly from the cortex to the spinal cord
through the corticospinal tract
c. Indirectsignals are also relayed through multiple accessory pathways
that involve the following structures
 0asal ganglia
 Cerebellum
 0rainstem nuclei

Note: In general, the direct pathwaysare concerned more with

discrete and detailed movements, especially of the
distal segments of the limbs, particularly the hands and
fingers.

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Corticospinal tract  0

Ess
 Tr 
 ³pyramidal tract´ S Persists throughout movement and is not
 most important output pathway from the motor cortex associated with any other neurological
 30% originates from primary motor cortex findings, easily distinguishing it from PD.
 giant pyramidal cells or 0etz cells
 30% from premotor cortex and supplementary motor areas b. Dystonia
 40% from somatosensory areas c. Seizures
d. Involuntary movements
Pathway:  Chorea
 Tardive dyskinesia
a. Cortex then through the posterior limb of the internal capsule  Athetosis
b. 0rainstem forming the pyramids of the medulla  Pseudoathetosis
c. The majority of the pyramidal fibers cross the lower medulla to the  Choreoathetosis
opposite side and descend into the lateral corticospinal tracts of  0allism
the spinal cord
 Terminates on the interneurons in the intermediate regions e. Clonus/myoclonus
of the spinal cord gray matter f. Spasm
 Some fibers relay neurons in the dorsal horn  Muscle cramps
 Very few fibers terminate directly on the anterior motor  Oculogyric crisis
neurons that cause muscle contraction  Hemifacial cramps
d. A few fibersdo not cross to the opposite side of the medulla but  Palatal myoclonus
pass ipsilaterally down the cord in the ventral (anterior)  Nystagmus
corticospinal tracts  0lepharospasm
e. Many if not most of the fibers eventually cross to the opposite side  Hiccup
of the spinal cord either in the neck or in the thoracic region.
f. These fibers may be concerned with the control of bilateral g. Amyotrophic Lateral Sclerosis
movements by the supplementary motor cortex.  Results in death of the lower motor neuron and subsequent
denervation of the muscle.
a Normal motor function depends on intact upper and lower motor  causes twitching of the fibers known as fasciculations, which
neurons, sensory pathways and input from a number of other can be seen on gross inspection of affected muscles.
neurological systems.
a Disorders of movement can be caused by problems at any point within
this interconnected system. PALPATION

The major muscle groups to be palpated include:

Ý

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{ 
a. 0iceps
INSPECTION b. Triceps
c. Deltoids
Normal Findings: d. Quadriceps
 No muscle movement when the limb is at rest. e. Hamstrings

Pathologic Findings: a Palpation should not elicit pain.

a. Tremors
 Specific type of continuous, involuntary muscle activity that Assessment of Muscle Symmetry and Muscle 0ulk
results in limb movement,
 Somewhat subjective and quite dependent on the age, sex and the
S Parkisonian activity or fitness level of the individual.
S resting tremor of the hand (the head and other
body parts can also be affected) that diminishes Example:
when the patient voluntarily moves the affected  A frail elderly personwill have less muscle bulk then a 25 year old
limb. body builder.

S Metabolic  Should be appropriately developed, after making allowances for the

 Cerebellar patient¶s age, sex, and activity level.
 Essential rubral  Some allowance must be made for handedness
 Physiologic tremor
 Tremor of Hepatic encelopathy

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 b. Normal muscle generates some resistance to movement when a
P c
 : limb is moved passively by an examiner
 Small, continuous resistance to passive movement
a. Pati nt shl
b in a gwn s that th a as f int st a
xps
. Patholoic fin
ins:
b. Ca flly xamin th maj mscl g ps f th pp an

lw xt miti s. a. Decrease

(flacci
)
c. Mscl g ps shl
app a symm t ically
v lp
wh n  occurs when the lower motor neuron is cut off from the
cmpa
with th i cnt pa ts n th th si
f th b
y. muscles that it normally innervates

. If th is asymm t y, nt if it fllws a pa ticla patt n
. Ass ss an
cmpa th blk f pp an
lw xt miti s b. Flacci
ity
f. Ass ss if anth p c ss (sgg st
by hist y  th asp cts  Complete absence of tone.
f th xam) has slt
in limit
mv m nt f a pa ticla limb
g. Palpatin f th mscl s will giv y a s ns f n
lying c. Increase
(spastic/rii
)
mass.  Occur when the upper motor neuron no loner functions.
h. Cmpa :  Affecte
limb is hel
in a flexe
position an
the examiner
 Left to Right may be unable to move the joint.
 Proximal vs. Distal  Seen most commonly followin a stroke, which results in the

eath of the upper motor neuron cell bo
y in the brain.
Patholoic fi

i
s:

. Increase
tone (hypertonicity)
 Peripheral or LMN i
jury  results from muscle contraction.
 Muscles lose their i

ervatio
s a

become very atrophic
with asymmetry followi
 a particular
erve
istributio
. e. Parkinson¶s Disease (PD)
 Causes increase
tone, eneratin a ratchet-like sensation
 Spi
al cor
tra
sectio
(known as co wheelin) when the affecte
limbs are
 Tra
sactio
at the thoracic level may cause upper extremity passively move
.
muscle bulk to be
ormal or eve
i
crease

ue to
i
crease

epe

e
ce o
arms for activity, mobility, etc. f. Deenerative joint
isease of the knee
 Muscles of the lower extremity will atrophy
ue to loss of  Mit cause limite
rane of motion, tou tone soul
still
i

ervatio
a

subseque
t
isuse. be normal.
 Fracture
 0roken leg that has recently been liberated from a cast will Note: Disorders that do not directly affect the muscles, upper
appear markedly atrophic. or lower motor neurons can still alter tone. This is a
disorder of the Extra Pyramidal System (EPS). The EPS
 Atrophy normally contributes to initiation and smoothness of
 Hands (assess and compare thenar eminence) movement.
 Shoulders
 Thighs

Assessment of Muscle Tone MANUAL MOTOR TESTING

P oce
u e:  Strent testin must take into account te ae, sex an
fitness level of
te patient.
a. Ask patient to elax the joint that is to be teste

b. Ca efully move the limb th ough its no mal ange of motion, being Example:
ca eful not to maneuve it in any way that is uncomfo table o  A frail, elderly, bed bound patient may have muscle weakness
gene ates pain. due to severe deconditioning and not to intrinsic neurological
c. Flex an
exten
the patient¶s finge s, w ist, elbow, shoul
e s disease.

. Flex an
exten
the patient¶s ankle an
knee, hips
 Interpretation must also consider the expected strength of the muscle
Note: If the patient has recently injured the area or are in pain, group being tested.
do not perform this aspect of the exam.
 The quadriceps group, for example, should be much more powerful
than the 0iceps.
No mal fin
ings:

a. When a muscle g oup is elaxe

, the examine shoul
be able to
easily manipulate the joint th ough its no mal ange of motion.
 This movement should feel fluid

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c c
 :
d. Wrist flexion (C 7, 8, T 1)
a. Maj Mscl G ps
 In the screening examination, it is reasonable to check only Mscle bein tested:
the major muscles or muscle groups.  Flexor carpi radialis
 More detailed testing can be performed in the setting of  Flexor carpi ulnaris
discrete/unexplained weakness.
Innervaion:
b. Intrinsic muscles of the hand (C 8, T 1)  Median nerve
 Ulnar Nerves.
Muscle bein tested:
 Interossei crce
re:
Innervtion:  Have the patient try to flex their wrist as you provide
 Ulnar nerve resistance.
Procedure:  Test each hand separately.
 Ask the patient to spread their fingers apart against
resistance (abduction).
 Then squeeze them together, with your fingers placed in
between each of their digits (adduction).
 Test each hand separately

e. Wrist extension (C 6, 7, 8)

Msce bein teste

:
 Extensor Radialis muscles
c. Flexors of the fingers (C 7, 8, T1)
Innervation:
Mscle being tested:  Radial Nerve
 Flexor DigitorumProfundus crcedre:
Innervtion:  Have the patient try to extend their wrist as you provide
 Median (radial ½) and Ulnar (medial ½) Nerves resistance.
crcedre:
 Ask the patient to make a fist, squeezing their hand around
two of your fingers.
 If the grip is normal, you will not be able to pull your fingers
out.
 Test each hand separately.

Note: Damage to the radial nerve results in wrist drop (loss of

ability to extend the hand at the wrist). The nerve can be
compressed against the humerus for a prolonged period
of time(known as a ³Saturday Night Palsy´).

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f. Elbow Flexion (C 5, 6) h. Shoulder Adduction (C5 thru T1)

Muscle being tested: Muscle being tested:

 0rachialis Muscle (along with the 0iceps Muscle)  Pectoralis Major through the Latissimus

Innervation: Innervation:
 Musculocutaneous Nerve  Lateral pectoral nerve
 Medial Pectoral nerve
Procedure:  Thoracodorsal nerve
 Have the patient bend their elbow to ninety degrees while
keeping their palm directed upwards. Procedure:
 Then direct them to flex their forearm while you provide  Have the patient flex at the elbow while the arm is held out
resistance. from the body at forty-five degrees.
 Then provide resistance as they try to further adduct at the
shoulder.

g. Elbow Extension (C 7, 8)

Mscle bein teste

:
 Triceps muscle i. Shoulder Abduction (C 5, 6)

I

ervi
: Muscle being tested:

 Radial nerve  deltoid muscle

Procedure: Innervation:
 Have the patient extend their elbow against resistance while  axillary nerve
the arm is held out (abducted at the shoulder) from the body
at ninety degrees Procedure:
 Have the patient flex at the elbow while the arms is held out
from the body at forty-five degress.
 Then provide resistance as they try to further abduct at the
shoulder.

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j. Hip Flexion (L 2, 3, 4) Innervation:
 Superior gluteal nerve
M cle bein e e
:  Inferior gluteal nerve
 Iliopsoas muscle
Procedure:
I

e aio
:  Place your hands on the outside of either thigh
 femoral nerve  Direct the patient to separate their legs against resistance.

croce
re:
 With the patient seated, place your hand on top of one thigh
and instruct the patient to lift the leg up from the table.

m. Hip Adduction (L2, 3, 4)

Muscle being tested:

 Adductor longus
k. Hip Extension (L5, S1)
 Adductor brevis
 Adductor magnus
Muscle being tested:
 Gracilis
 gluteus maximus,

I

rai
:
Innervation:
 Obturator nerve
 inferior gluteal nerve.

Procedure:
Procedure:
 Place your hands on the inner aspects of the thighs.
 With the patient lying prone, direct the patient to lift their leg
 Direct the patient to close their legs against resistance.
off the table against resistance.

l. Hip Abduction (L 4, 5, S1)

n. Knee Extension (L2, 3, 4)
Muscle being tested:
 Gluteus maximus Muscle being tested:
 Gluteus medius (primarily)  quadriceps muscle group
 Gluteus minimus
Innervation:
 femoral nerve

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 Procedure:
 Have the seated patient steadily press their lower extremity
into your hand against resistance.

Note: The peroneal nerve is susceptible to injury at the point

where it crosses the head of the fibula (laterally, below
the knee). If injured, the patient develops ³Foot Drop,´
an inability to dorsiflex the foot.
o. Knee flexion (L5, S1, 2)

Muscle being tested: q. Ankle Plantar Flexion (S 1, S 2)

 Hamstring muscle group
Muscle bein tested:
Innervation:  Gastrocnemius
 Sciatic nerve  soleus

Procedure: Innervation:
 Have the patient rest prone.  sciatic nerve
 Then have them pull their heel up and off the table against
resistance. Procedure:
 Have the patient ³step on the gas´ while you provide
resistance.

p. Ankle Dorsiflexion (L4, 5)

Mscle bein ese

: Note: Plantar flexion and dorsiflexion can also be
 tibialis anterior assessed by asking the patient to walk on their
toes (plantar flexion) and heels (dorsiflexion).
Inneration:
 deep peroneal nerve

crocedre:
 Direct the patient to pull their toes upwards while you
provide resistance with your hand.

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  Sb w k
c
b 

 c.

Ý
  Py 

 w  p
 wk ,  


    



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  ,   p 


w
   
p 
,
G 

   c 
: v 
  x

b , c.

G 
D c p
a Pronator drift
0/5 N v 
  Test for detecting slight weakness of the upper extremities.
1/5 S c
 cy b
 j
 

2/5 Mv 
  j
, b
 
  vy Procedure:
3/5 Mv 
 
  vy, b
 
 

 Ask the patient to stand for 20-30 seconds with both arms
 
c straight forward, palms up, and eyes closed.
 Instruct the patient to keep the arms still while you tap them
4/5 Mv 
 
  
c , b  

 
briskly downward.
5/5 N  

 The patient will not be able to maintain extension and
supination (and "drift into pronation) with upper motor
Acc

  H  
: M c S

neuron disease.

G 
D c p

Common peripheral neres, inneration and clinical correlation:
0 N v 

1 Fck   c  c
 c
b
  c

Spinal
v 
   j
 Peripheral Sensory Motor Clinical
Nere
2 Mv 
w  vy 

Nere Inneration Inneration Correlation
Roots
3 Mv 
 
  vy, b
 
  
c 0ack of Wrist At risk for
4- Mv 
 
 
 
c Radial thumb, extension C6, 7, 8 compression at
4 Mv 
 
 
  
c Nere index, and humerus,
4+ Mv 
 
  
  
c middle, and abduction of known as
5 F pw ½ ring finger; thumb in "Saturday Night
back of palmer plane Palsy³
A
v T   M c G 

: forearm
At risk for injury
. P y  Ulnar Nere Palmar and Abduction of C7, 8 with elbow

 v 
 dorsal fingers and T1 fracture.
b. S v w k
aspects of (intrinsic Can get
 v 
 w  vy 

pinky and ½ muscles of transient
c. M
 w k
of ring finger hand) symptoms
 v 
 
  vy b
 
 
 
c when inside of

. M
w k
elbow is struck
 v 
 
 
  
c ("funny bone"
. F 
 distribution)
Palmar
Pc 


 : Median aspect of the Abduction of C8, T1 Compression at
Nere thumb, thumb carpal tunnel
. My  index, perpendicula causes carpal
  c


c c z
by 
pc  c 

middle and r to palm tunnel
 c  p
  xp 
c w k
b
 p
½ ring finger; (thenar syndrome
palm below muscles).
b. Mypy these
  y p
 w p x  c w k
fingers.
. Can become
c. P p 
 py Lateral Lateral L1, 2 compressed in
  y p
 w
  w k
Cutaneous aspect thigh obese patients,
Nere of causing

. UMN
y 
c
Thigh numbness oer
  y p
 w py 
 w k
its distribution
Can be injured
Note: The largest and most powerful groups are those of the Peroneal Lateral leg, Dorsiflexion L4, 5; S1 with proximal
quadriceps and hamstrings of the upper leg top of foot of foot fibula fracture,
(tibialis leading to foot
Sp c    b w k
: anterior drop (inability to
muscle) dorsiflex foot)

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 £
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{ £ b. 0alance
 Assess if they veer off to a particular side
 Ability to stand and walk normally is dependent on input from several
systems, including: c. Rate of walking
 Visual  Assess how fast or how slow they move during walking
 Vestibular  Are they slow moving secondary to pain/limited range of
 Cerebellar motion in their joints, as might occur with degenerative joint
 Motor system disease or due to Parkinson¶s disease?
 Sensory system
 The precise cause(s) of the dysfunction can be determined by d. Attitude of Arms and Legs
identifying which aspect of gait is abnormal and incorporating this  Assess loss of movement and evidence of contractures
information with that obtained during the rest of the exam. (example:post-stroke)?
 Assess movement of arms and legs.
crocedure:  Look for presence of arm swing during walking
 Walk across the room, turn and come back
 Walk heel-to-toe in a straight line e. Heel to Toe Walking
 Walk on their toes in a straight line  Ask the patient to walk in a straight line, putting the heel of
 Walk on their heels in a straight line one foot directly in front of the toe of the other.
 Hop in place on each foot S referred to as tandem gait
 Do a shallow knee bend S a test of balance
 Rise from a sitting position S may be difficult for older patients (due to the frequent
coexistence of other medical conditions) even in the
catoogic fin
ings: absence of neurological disease.

 c 

 D  cathologic findings:

S Difficulty getting out a chair and initiating movement
 3  
 
a. Loss of balance suggests impaired proprioception.
S Patient presents with lack of balance and a wide based gait
b. carkinson¶s Disease
 Movement start off slow and then accelerate, perhaps losing
STATION TESTING control of their balance or speed

a. Equilibratory testing(balance testwith romberg test) c. Cerebellar ataxia

 0alance impairment is not ameliorated by visual orientation
Procedure: U In cerebellar lateral lobe lesion
 Have the patient stand in one place. S falling is toward the affected side
 This is the test for balance incorporating input from the visual, U In frontal lobe lesion
cerebellar, proprioceptive, and vestibular systems. S falling is to the opposite side
 If they are able to do this, have them close their eyes, removing U In lesion at the midline or vermis
visual input (Romberg test) S falling indiscriminately
 Ask the patient to stand from a chair, walk across the room, turn, U Lesion on both hemispheres
and come back towards you. S generalized loss of balance

b. Heel to toe walking (tandem gait)

COORDINATION/ CERE0ELLAR TESTING
crocedure:
 Ask the patient to walk in a straight line, putting the heel of one  The cerebellum fine tunes motor activity and assists with balance.
foot directly in front of the toe of the other.  Dysfunction results in a loss of coordination and problems with gait.
 This also a test of balance.  The left cerebellar hemisphere controls the left side of the body and
 This may be difficult for older patients (due to the frequent vice versa.
coexistence of other medical conditions) even in the absence of  For the screening exam, using one modality will suffice.
neurological disease.
Assess the following:  If an abnormality is suspected or identified, multiple tests should be
done to determine whether the finding is durable.
a. Difficulty getting up from a chair
 Assess ease of rising from a sitting position Note: If the abnormality on one test is truly due to cerebellar
 Problems with this activity might suggest proximal muscle dysfunction, other tests should identify the same
weakness, a balance problem, or difficulty initiating problem. Gait testing is an important part of the
movements. cerebellar exam.

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a. Finger to nose test Differences between UMN and LMN paralysis:

croce
re: UMN or Supranuclear paralysis LMN or nuclear-infranuclear
 With the patient seated, position your index finger at a point in paralysis
space in front of the patient.  Muscles affected in groups;  Individual muscles may be
 Instruct the patient to move their index finger between your finger never individual muscles affected
and their nose.  Atrophy slight and due to  Atrophy pronounced; up to
 Reposition your finger after each touch. disuse 70% of total bulk
 Test the other hand  Spasticity  Flaccidity and hypotonia of
affected muscles
Interpretaton:  Hyperactivity of the tendon  Loss of tendon reflexes
 Patient should be able to do this at a reasonable rate of speed, reflex
trace a straight path, and hit the end points accurately.  Extensor plantar reflex  Plantar reflex, if present, is of
(0abinski sign) normal flexor type
Pathologic findings:  Fascicular twitches absent  Fasciculations may be present
 Missing the mark, known as dysmetria, may be indicative of  Normal nerve conduction  Abnormal nerve conduction
disease. studies studies
 No denervation potentials in  Fibrillations, fasciculations,
b. Rapid alternating movements EMG positive sharp waves in EMG
 (+) weakness  (+) weakness
crocedre:
 Increased tone  Decreased tone
 Ask the patient to touch the tips of each finger to the thumb of the
same hand.
 Test both hands.

Inte  etaton:
 The movement should be fluid and accurate.

catholoic findins:
 Inability to do this, known as dysdiadokinesia, may be indicative
of cerebellar disease.

c. Heel to shin testing

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

Interretton:
 The movement should trace a straight line along the top of the
shin and be done with reasonable speed.

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