summary of Motor tests

Inspection  

·         Left and right, proximal to distal.

·         Posture

·         Asymmetry

·         Abnormal involuntary movements

o    Fasciculations

§  Each strings of muscles moving involuntarily - “bag of worms”

o    Tremor

o    Chorea

§  A repetitive movement - dance-like

o    Dystonia

§  sustained muscle contractions cause twisting and repetitive movements or abnormal postures

o    Myoclonus

§  Twitching

·         Atrophy

·         Hypertrophy

·         Muscle bulk

o    Primarily assessed by inspection. Shape is important.

o    Bulk accounts the

o    Size

o    Activity level

o    Age of patient

o    Bulk reduced, look for symmetry

o    Severe atrophy suggests paralysis

Palpation / movement

·         Tone -

o    tone is the resistance offered by the muscle due to its partially contracted state.

·         Technique of examining tone

o    Ensure patient relaxed

o    Best with lying down

o    Support limb and move it. Passively over all major joints

§  Support both sides of a joint. E.g. in a knee joint, hold the femur and the shin and move.

o    Increased in UMN

o    Decreased in LMN lesion

·         Tone difference

o    Spasticity (clasp knife)

§  Assessed by quick flexion/ extension of elbow or quick supination (swiss knife)

§  UMN lesion

o    Rigidity (lead pipe)

§  Continuous resistance to passive movement not velocity dependant. Movement should be performed slowly.

§  Seen in extrapyramidal disorders

§  Parkinsonism

§  Cogwheel

o    Hypotonia

§  Very flaccid limbs. Less muscular tone.

§  Seen in LMN lesions.

Power

o    Tested by comparing the patient and your strength

o    Supine

o    Compare right/left

o    Proximal to distal

o    Grading

§  0 - no contraction

§  1 - flicker or trace of contraction

§  2 - active movement with gravity eliminated

§  3 - active movement against gravity

§  4 - active movement against gravity and resistance

§  5 - normal power

o    “please resist me”

o    Regions

§  Upper limbs

·         §  Shoulder

o    4 movements (no rotation)

·         §  Elbow

o    Flexion and extension

o    Ask patient to bend elbow first - like a fighting pose for ease

o    Wrist

o    Ask patient to clench fist (so that fingers are not tested)

o    Flexion and extension

·         §  Hand

o    Opposition of thumb

o    Abduction - squeeze abducted fingers

o    Adduction - ask to hold card using 2 adjacent fingers.

o    Squeeze hand (grip)

§  Lower limb

·          Hip

o    4 movements (no rotations)

o    Abduction

o     Adduction

o     Flexion

o     extension

·          Knee

o    Easier with patient’s leg flexed (while lying supine)

o    Flexion extension.

o     Ankle

§  Planter, and dorsiflexion

o     Toes

Deep tendon reflexes

·         HOLD Tendon hammer the RIGHT WAY -

o    lower 1/3 of hammer

o    Move only at the wrist

o    Single strike

o    Ask patient to relax

o    Observe for muscle contraction and limb movement

o    Reflex response depends on the force of stimulus

o    Responces

§  Hyperactive

§  Normal

§  Diminished

§  Absent

o    Reflexes can be reinforced by having patient perform isometric contraction of other muscles

·         Jendrassik maneuver

o    Ask patient to clench teeth and pull hooked fingers

·         Where to do?

o    Biceps

o    Brachioradialis

§  Hands Down and bent -stretch tendon so easier to elicit

o    Triceps  

§  Bend elbow - stretch tendon

o    Knee

o    Ankle

o    Above umbilicus - superficial

o    Below umbilicus - superficial

o    Planter - (babinski)

§  Clonus - IF hyperreflexia

o    Involuntary, rhythmic and repetitive muscular contractions

o    Occur in…

§  Ankles

§  Wrist

§  Patella

o    If reflexes are hyperactive, test for ankle clonus

§  Do it the right way - clonus is best elicited when leg is lifted off the bed.

§  Up-down-up-down-jerk!

o    Also hoffman’s reflex

§  Flick the finger inwards while hand relaxed

§  Observe the thumb - positive sign is thumb flicking inward.

o    Fasciculation - positive

o    Knee clonus

§  Sharply push with thumb and forefinger above patella

o    Abdominal

o     cremasteric

o    Planter reflex (babinski)

§  Explain to patient to ask to relax

§  Hold leg at mallulus

§  Use a key, stroke lateral aspect of sole of each foot and then come across the ball of foot medially with a sharp object

§  Make sure not too sharp

Co-ordination

·         Test for Nyastigmus - ask patient to look at finger - move finger horizontally and vertically

·         “British constitution”

·         Rapid alternating movement

·         Lat-tali-lat-ta movement

·         Finger-to-nose test

·         Heel-to-shin testing

·         Toe-to-finger testing

·         Procedure

·         explain

·         Make sure you show how to do it before testing.

·         Do faster

·         Romberg’s test

o    Prepare to catch

o    Ask patient to stand and closed eyes

o    Positive if unstable

Gait

·         Ask patient to walk in a straight line

·         Tandem walk

ask patient to walk in such a way that heel and toe touch - like a circus rope-walking act.

differentiation between UMN and LMN

	UMN	LMN
Anatomical location	Everything else	Anterior horn cells
Muscle wasting	Muscle Groups	Specific muscle
fasciculation	Not present	present
Tonicity	Hypertonia / spacicity	Hypotonia / flaccid
Tendon reflexes	Hyperreflexive	Diminished / absent
Abdominal reflex	Lost	Lost IF T8-12
clonus	Appreciated
babinski	Toe go up	negative

Clinical school material

In clinical school, you are required to know the root values of the power examination, and tendon reflexes you test for.

Power

Region of exam	Type of movement	Root values
shoulder	abduction	C5
	adduction	C6, 7
elbow	flexion	C5, 6
	extension	C7
wrist	flexion	C6, 7
	extension	C6, 7
fingers	Flexion	C8
	Extension	C7, 8
	Abduction	T1
	adduction	T1
hips	Flexion	L1,2,3
	Extension	L5, S1
	Abduction	L4, 5, S1
	Adduction	L2, 3,4
Knee	Flexion	L5, S1
	Extension	L3, L4
ankle	Planter flexion	S1, S2
	Dorsiflex	L4, L5

Tendon reflexes

Biceps	C5, C6
Brachioradialis	C5, C6
Triceps	C7
Knee	L3, L4
ankle	S1, S2
Abdominal	Upper - T8-9 Lower - T10-11
plantar	L5, S1, S2