Examination Of The Motor

System
Practical Physiology Lab

Anatomy
• Fibers of the corticospinal tract arise from
precentral gyrus (2/3 of it) and from
postcentral gyrus (1/3 of it), the descending
fibers then pass through the internal capsule
,at the junction of the medulla oblongata and
the spinal cord.
• most of the fibers cross the
midline at the decussation of
the pyramid to form the
lateral corticospinal tract
80%, the remaining fibers do
not cross but descend as
anterior corticospinal tract
20%, these fibers eventually
cross the midline and
terminate in the anterior
gray column of the spinal
cord segment in the cervical
and upper thoracic regions.

upper vs lower motor neuron lesion

Neurological examination of the motor
system consists of:
• Inspection of muscle groups
• Elicitation of muscle tone
• Testing of muscle power
• Elicitation of deep tendon reflex and superficial reflex
• Testing of coordination

From the above parameter we can decide whether the disease

affecting upper motor neuron or the lower motor neuron.
Upper motor neuron means the corticospinal tract while lower
motor neuron means peripheral spinal nerve and anterior
horn cell.

Inspection of muscle group

1. Bulk of muscle: any significant
difference in the bulk of muscle between
both sides of the body can be assessed.
The size or bulk of voluntary muscle varies
with age, sex, body build, state of nutrition
and muscular exercise.
Abnormalities include
a) Atrophy: - In atrophy or wasting, the
muscle becomes small in size. This can
occur due to disuse, neurological
disorders, joint injury or joint diseases.
b) Hypertrophy: the bulk of the muscle
increases eg, muscular dystrophies. In
pseudomuscular dystrophy due to
pathological changes in the muscles, the
muscle bulk increases, but these enlarged
muscles are weak inspite of their size.
2. Fasciculation: subcutaneous twitching overling muscle
bellies when the muscle are at rest.
wasting and fasciculation is the feature of lower motor
neuron disease
3. Tremor: rhythmic movement resulting from
contraction and relaxation of groups of muscles.

4. abnormal position
of a joint or a limbs

Assessment of muscle tone

• Muscle tone is defined as the resistance felt

when a joint is moved passively through its
range of movement (resistance of the of
muscle to stretch).
• The tone is assessed by asking the person to
relax completely and then passively moving
the joints of the upper and lower extremities.
The resistance offered by the muscle during
passive movement represents the degree of
muscle tone.
• Abnormalities:
1) Hypertonia: Increase
in muscle tone.

a) Spasticity
b) Rigidity

2) Hypotonia: Decrease in muscle tone. There is decreased

resistance to passive movement there is increased range of
movements in the limbs. This is seen in lower motor neuron
lesion and cerebellar lesions. usually associated with
,hyoreflexia and muscle wasting.

Examination of muscle tone

• Ask the patient to relax
• Passively flex and extend each joint in turn
• In the upper limb test tone at shoulder, elbow and wrist joint
• In the lower limb by internally and externally rotating the leg

• Knee clonus is done by sharply push the patella towards the

foot with the knee extended
• Ankle clonus is done by support the flexed knee with one
hand in the popliteal fossa, then using the other hand briskly
dorsiflex the foot and sustain the pressure.
• ( if knee clonus is present, the patella will jerk
up and down, if ankle clonus is present, there
will be rhythmic beating of the foot)
• Clonus: Is rhythmic series of involuntary
muscle contractions evoked by sudden
maintained stretch of the muscle.
It is hard neurological sign indicating upper
motor neuron disease

Test of the muscle power

• Muscle power is generally recorded using the grading

system which divides muscle power to 6 grades:
• Grade 0 (Absent): no muscle contraction is visible or
detected.
• Grade 1 (Trace): muscle contraction visible but no
movement at joint.
• Grade 2 (Weak): joint movement with the gravity or when it
is eliminated (sideways)
• Grade 3 (Fair): movement against the gravity (upward)
• Grade 4 (Good): movement against the gravity and added
resistance
• Grade 5 (Normal): normal power
• Test muscle strength by having the patient moves
his joint actively against your resistance.
• Compare one side with the other.
• If muscle weakness is found, compare the
proximal and distal strengths.
• In general, proximal weakness is related to
muscle disease (myopathy); while distal weakness
is related to neurologic disease (neuropathy).

Test the following:

1.Flexion at the elbow
(C5, C6, biceps)

2.Extention at the elbow

( C6,C7,triceps )
3.Extension at the wrist (C6, C7, C8, radial nerve)

4. Test the patient's grip by having the patient

hold the examiner finger (‘’grip’’ C7, C8, T1)

5.Finger abduction (C8, T1, ulnar nerve)

6.Oppostion of the thumb (C8, T1, median
nerve)

7. Flexion at the hip (L2, L3, iliopsoas)

8. Adduction at the hips (L2, L3, L4, adductors)

9. Abduction at the hips (L4, L5, S1, gluteus

medius and minimus)
10.Extension at the hips (S1, gluteus maximus)

11. Extension at the knee (L2, L3, L4, quadriceps)

12. Flexion at the knee (L4, L5, S1, S2,

hamstrings)

13. Dorsiflexion at the ankle (L4, L5)

14. Plantar flexion (S1)

Reflexes
Two main types of reflexes:
• Deep tendon reflexes.
• Superficial reflexes.

Tendon Reflex Grading Scale:

• (0 ) No response
• (1+) Diminished
• (2+) Normal
• (3+) Increased
• (4+) Hyperactive

• Test each reflex, and compare it with the other side.

• Reflexes should be symmetrically equal.
Hyperactive reflexes are characteristic of:
1. pyramidal tract disease.
2. Electrolyte abnormalities
3. Hyperthyroidism and other metabolic abnormalities
Diminished reflexes are characteristic of:
1. Anterior horn cell disorders
2. Myopathies.
3. Decrease in muscle bulk.

• Patients with hypothyroidism have decreased relaxation after

a deep tendon reflex, which is termed a hung reflex.
• In a patient with a diminished reflex, the technique of
reinforcement may be useful. By asking the patient to perform
isometric contraction of other muscles, the generalized reflex
activity may be increased. When testing reflexes in the upper
extremities, have the patient clench the teeth or push down
on the bed with the thighs. When testing reflexes in the lower
extremities, have the patient lock fingers and try to pull them
apart at the time of testing. This procedure is sometimes
called Jendrassik's maneuver.

A. Deep tendon reflexes:

1. Biceps (C5, C6)

* The patient's arm should be partially flexed at
the elbow with the palm down.
* Place your thumb or finger firmly on the
biceps tendon.
*Strike your finger
with the reflex hammer.
2. Brachioradialis (C5, C6)
* Have the patient rest the forearm on the
abdomen or lap. 2.Strike the radius about 1-2
inches above the wrist.
*Watch for flexion and supination of the
forearm.

3. Triceps (C6, C7)

*Support the upper arm and let the patient's
forearm hang free.
*Strike the triceps tendon above the elbow with
the broad side of the hammer.
*If the patient is sitting
or lying down, flex the
patient's arm at the
elbow and hold it close
to the chest.
4. Knee (L2, L3, L4)
*Have the patient sit or lie down with the knee
flexed.
*Strike the patellar tendon just below the
patella.
*Note contraction of the
quadriceps and extension
of the knee and extension
at the knee should be observed.

5. Ankle (S1, S2)

* Dorsiflex the foot at the ankle.
* Strike the Achilles tendon.
* Watch and feel for plantar flexion at the ankle.
B. Superficial reflexes:

1. Plantar Response (Babinski):

* Stroke the lateral aspect of the sole of each
foot with the end of a reflex hammer or key.
* Note movement of the toes, normally flexion
(withdrawal).
* Extension of the big toe with fanning of the
other toes is abnormal. This is referred to as a
positive Babinski.

In normal condition, the reflex arc of the pyramidal system

suppresses that of the extrapyramidal system and therefore
downward bending of the toes (planter flexion) is elicited in
response to sensory stimuli from the bottom of the feet.
However, when the damage occurs to the pyramidal system
without involving the extrapyramidal system, the same tactile
stimulus to the sole will produce extension of the great toe and
fanning outward of other toes (dorsiflexion). This type of
response is called the Babinski sign
2. Corneal (conjunctival) reflex (Aff V Eff - VII
cranial): The sclerocorneal junction is touched
with a wisp of cotton. Observation: Closure of
eyelids.

3. Pupillary reflexes (Aff - II, Eff = III cranial):

a. Light reflex: They are of two types:
1. Direct light reflex: The subject is asked to sit in a dimly
lit room. A beam of bright light using a torch is thrown on
one eye - Constriction of the pupil on the illuminated eye.
Similarly the other eye is tested.
2. Indirect light reflex (consensual light reflex): A beam of
light is thrown on one eye the other eye is observed -
Constriction of the pupil on the opposite side.
B. Accommodation reflex: The subject is asked to look
distant object. The size of the pupil is noted. Immediately
the subject is asked to look at the finger placed in front of
his eyes. Pupillary constriction is observed.
4. Abdominal reflex (T6-T12):
The skin of the anterior abdominal wall is
gently stroked on the four quadrants with
the sharp end of the knee hammer obliquely
Contraction of the muscles on the side stroked.

5. Cremastric reflex (L1, L2): The medial side of the thigh is

stroked in the male subject - Elevation of the testicle or the
scrotal sac of the same side.
6. Anal reflex (S3, S4): The skin around the anus is stroked -
Contraction of the anal
sphincter.

Cerebellar Function
• Cerebellar function is tested by the following (role of 10):
1. Slurred Speech
2. Nystagmus: a vision condition in which the eyes make repetitive,
uncontrolled movements.
3. Finger-to-nose test: Patients with cerebellar disease persistently
overshoot the target, a condition known as past pointing/dysmetria.
4. Rapid alternating movement: The ability to perform rapid
alternating movements is called diadochokinesia. An abnormality in
performing rapid alternating movements is called adiadochokinesia.
5. Rebound phenomenon
6. Intention Tremor
7. Tone
8. Heel-to-knee test
9. Pendular reflex :in which the leg continues to move several times
after the initial reflex
10. Tandem gait & Romberg's test : Ask the patient to close his eyes
but be prepared to catch the patient. Repeatedly falling is a positive
result.
Thank you