MOTOR EXAMINATION

Dr. Ebad Ur Rehman Ghouri (PT)

 CONTENT

 Motor System
 Elements of motor System Examination
 Examination of Muscle Bulk
 Examination of tone
 Abnormal Tone
 Examination of Muscle Strength
 Examination of Superficial Reflexes
 Examination of Deep Tendon Reflexes
 OBJECTIVES

➢ At the end of the lecture the students will be able

to;
 Define Motor System Examination & its Divisions
 Describe the Elements of Motor System
Examination
 Describe Common Deficits Associated with
Disorders of Motor System
 STEPS OF NEUROLOGICAL EXAMINATION

❖ History, Systemic Review, Test & Measure

❖ Examination of mental status and higher function

❖ Examination Of Cranial Nerves

❖ Examination Of Motor System

❖ Examination Of Sensory System

❖ Examination Of Balance & Coordination

 MOTOR SYSTEM

❑ The system involved in generation and control of voluntary

and reflex movements.
❑ The motor system can be divided into the

(1) Peripheral apparatus, which consists of the anterior horn cell

and its peripheral axon, the neuromuscular junction, and
muscle &

(2) Central apparatus, which includes the descending tracts

involved in control (i.e. the pyramidal system) and the systems
involved in initiating and regulating movement (the basal
ganglia and cerebellum).
 ELEMENTS OF MOTOR SYSTEM EXAMINATION

❑ Examination for motor system includes assessment

of ;

➢ Muscle Bulk
➢ Muscle Tone
➢ Muscle Strength &
➢ Reflexes
 MUSCLE BULK

❑ The motor examination should start with an inspection of any

muscle bulk asymmetry.

 Muscle bulk is the amount of muscle mass or accounting for

size of muscle
 Specific muscles and the compartments affected should be noted.
 An accurate assessment of muscle bulk using a tape measure
should be performed. This can be done by first marking the
extremity from a fixed bone landmark so that the corresponding
areas of the affected and unaffected limbs can be compared.
 MUSCLE BULK OBSERVATION/PALPATION

❑ The muscle bulk includes

looking at the muscles for
❑ Atrophy (loss of muscle bulk or
wasting):
L calf hypertrophy and R
 Occur as a result of the loss of calf atrophy
functional mobility (disuse
atrophy)
 LMN disease (neurogenic
atrophy) or
 Protein caloric malnutrition
❑ Hyperatrophy (inc in size of L hand muscle wasting
muscle) from de-nervation
MUSCLE BULK: OBSERVATION

❑ Fasciculations:
o Random, spontaneous
twitching of muscle fibers
that are visible through
the skin

❑ If present with atrophy

indicates LMN disease
 EXAMINATION OF TONE

❑ Tone is defined as the resistance of the muscle to

passive elongation or stretch when an individual
attempts to maintain muscle relaxation.

❑ An examination of tone consists of

(1) Initial observation of resting posture & palpation

(2) Passive motion testing
(3) Active motion testing
 Initial Observation & Palpation

❑ Initial observation of the pt reveal abnormal posturing of the

limbs or body
❑ Careful inspection should be made regarding the position of
the limbs, trunk, & head
❑ Palpation of the muscle belly yield information about the
resting state of muscle
❑ Consistency, firmness & turgor should be examined
❑ Hypotonic muscles will feel soft & flabby
❑ Hypertonic muscles will feel taught & harder than normal
 Passive Motion Testing

 Reveals information about the responsiveness of

muscles to stretch.
 The pt is instructed to relax, letting the therapist
support & move the limb.
 During passive motion test the therapist should
maintain firm & constant manual contact,
moving the limb in all motions.
 Passive Motion Testing

 When tone is normal , the limb moves easily & the

therapist is able to alter direction & speed without
feeling abnormal resistance. The limb is responsive &
feels light.
 Hypertonic limbs generally feel stiff & resistant to
movement.
 Flaccid limbs feel heavy & unresponsive
 ABNORMAL TONE

❑ Tonal abnormalities are categorized as

1) Hypertonia/Spasticity
2) Hypotonia/Flaccidity
3) Dystonia
 ABNORMAL TONE

❑ Spasticity:
 Hypertonic motor disorder characterized by velocity
dependent resistance to passive stretch.

 Chronic spasticity is associated with contracture, abnormal

posturing, deformity, functional limitations & disability.

 It arises from injury to corticospinal pathways (pyramidal

tracts) & occur as part of UMN syndrome.

 S/S of UMN syndrome include hyperactive stretch reflex,

involuntary flexor & spasms, clonus, babinski’s sign,
exaggerated reflexes & loss of precise autonomic control.
 ABNORMAL TONE

❑ Hypotonia:
 Defined as decreased or absent tone.

 Resistance to passive movement is diminished, stretch reflexes

are dampened or absent, & limbs are easily moved (floppy)
 It results from the LMN lesions e.g. peripheral neuropathy,
cauda equina lesion, radiculopathy.

 S/S includes decreased or absent tone, decreased or absent

reflexes, muscle fasciculations & fibrillations with denervation
& neurogenic atrophy
 ABNORMAL TONE

❑ Dystonia:
 Hyperkinetic movement disorder characterized by disordered tone &
involuntary movements involving large portion of the body.
 Movements are similar to athetoid movements with typical twisting or
writhing motions

 It results from CNS lesion (Basal Ganglia), inherited (primary idiopathic

dystonia, neurodegenerative disorder ( wilson’s disease, parkinson’s
disease etc

 Dystonia represent in the form of focal dystonia (e.g. spasmodic

torticollis, or isolated writer’s cramp) & segmental dystonia ( e.g.torticollis
& dystonic posturing of the arm)
 EXAMINATION OF MUSCLE STRENGTH

❑ Muscle strength is the measurable force exerted

by a muscle or group of muscles to overcome a
resistance in one maximal effort.

❑ Testing:
 Muscle strength is tested by having the patient
resist examiner’s force as he attempt to move
pt’s body part against the direction of pull of the
muscle that examiner is evaluating.
 SCALE FOR GRADING MUSCLE STRENGTH

❑ Muscle strength is graded on a 0-5 scale

o 0 Zero (0) : No evidence of contraction by vision or palpation
o 1 Trace (T): Slight contraction, no motion
o 2 Poor (P): Movement through complete ROM in gravity
eliminated position
o 3 Fair (F): Movement through complete ROM against gravity
o 4 Good (G): Movement through complete ROM against
gravity; able to hold against moderate resistance; can be
broken (break test) at end range
o 5 Normal (N): Movement through complete ROM against
gravity; able to hold against maximum resistance; can not be
broken at end range
 MUSCLE GROUP TESTING

❑ Shoulder – Shrug, Abduction, Adduction, Flexion,

Extension, External & Internal Rotation
❑ Elbow -flexion & extension
❑ Wrist –Flexion & Extension
❑ Grip strength
 Interossei of Hand –Finger Abduction & Adduction
❑ Pronator Drift: A test for subtle upper extremity
weakness.
 Have patient stand, close their eyes & extend both
hands, palm up.
 E.g. If R arm slightly weak, it will pronate & “drift”
down ward.
MUSCLE GROUP TESTING
Movement Main muscles Nerve roots Peripheral nerve
tested
SHOULDER
Shrug Trapezius C2-5 Spinal accessory

Abduction Deltoid/supraspinat C5(6) Axillary/suprascapul

us ar
External Infraspinatus/teres C5(6) Suprascapular
rotation
Internal Pectoralis major C5-7 Lateral pectoral
rotation
Adduction Latissimus/pectorali C6-8 Suprascapular/pect
s oral
Flexion Deltoid/coracobr. C5-6 Axillary/musculocut.

ELBOW
Flexion Biceps/brachialis C5-6 Musculocutaneous
Brachioradialis Radial
Extension Triceps C6-7 Radial
 MUSCLE GROUP TESTING
Movement Main muscles Nerve roots Peripheral nerve
tested
WRIST
Flexion Flexor carpi radialis C6-7 Median
Flexor carpi ulnaris C7-8 Ulnar
Extension Extensor carpi radialis C6-7 Radial
Ext. carpi ulnaris C7-8 Deep radial
Pronation Pronator teres C6-7 Median
Supination Supinator C5-6 Radial
Biceps C5-6 Musculocutaneous
FINGER
Flexion Flexor digitorum mm. C7-8 Median (ulnar)
Extension Extensor digitorum C7-8 Deep Radial
Ab- & Iterosseous muscles
Adduction Ulnar
Thumb Abductor pollicis br. C8-T1
Median
Abduction
 MUSCLE GROUP TESTING

 Hip Flexion, Extension, Abduction &

Adduction
 Knee Flexion & Extension
 Ankle Flexion & Extension, Inversion &
Eversion
 Great toe Flexion & Extension
Movement tested Main muscles Nerve roots Peripheral nerve
MUSCLE GROUP TESTING
HIP
Flexion Iliopsoas L2-3 (L4) Lumbar plexus
Extension Gluteus max L5-S2 Inferior gluteal
Abduction Gluteus medius L5-S1 Superior gluteal
Adduction Adductor mm. L2-4 Obturator
KNEE
Flexion Hamstring L5-S1 Sciatic
Extension Quadriceps L2-4 Femoral
ANKLE
Dorsiflexion Tibialis anterior L4-5 (S1) Fibular (peroneal
Plantar flexion Gastroc/soleus S1 (S2) Tibial
Inversion Posterior tibial L5 (S1) Tibial
Eversion Fibular (peroneal) L5 (S1) Fibular (peroneal)
GREAT TOE
Dorsiflexion Extensor hallucis L5 (S1) Fibular (peroneal)
Plantar flexion Flexor hallucis (S1) S2 Tibial
 DEEP TENDON REFLEXES (DTR)

 A reflex is an involuntary, predictable, & specific response to

a stimulus dependent on an intact reflex arc.

 The deep tendon reflex results from stimulation of the stretch

sensitive IA afferents of the neuromuscular spindle producing
muscle contraction via monosynaptic pathway

 It is tested by tapping sharply over the muscle tendon with a

standard reflex hammer.

 To ensure adequate response, the muscle is positioned in

midrange & pt is instructed to relax.
 EXAMINATION OF DEEP TENDON REFLEXES

❑ Myotatic Reflex
▪ Jaw (CN 5)
❑ Stimulus:
▪ Pt is sitting, with jaw relaxed
& slightly open. Place finger
on top of chin; tap
downward on top of finger
in a direction which causes
jaw to open
❑ Response:
 Jaw rebounds & closes
 EXAMINATION OF DEEP TENDON REFLEXES

❑ Myotatic Reflex
▪ Biceps Musculocutaneous
nerve (C5-C6)
❑ Stimulus
▪ Pt is sitting with arm flexed &
supported. Place thumb
over the biceps tendon in
the cubital fossa, stretching
it slightly. Tap thumb or tap
directly on tendon
❑ Response:
▪ Slight contraction of elbow
flexors
 EXAMINATION OF DEEP TENDON REFLEXES

❑ Myotatic Reflex
 Bracheoradialis (supinator)
 Radial nerve (C5-C6)
❑ Stimulus:
 Pt is sitting with arm flexed
onto the abdomen. Place
finger on radial tuberosity &
tap finger with hammer
❑ Response:
 Slight contraction of elbow
flexors, slight wrist extension
or radial deviation
 EXAMINATION OF DEEP TENDON REFLEXES

❑ Myotatic Reflex:
▪ Triceps
▪ Radial nerve (C6-C7)
❑ Stimulus:
▪ Pt is sitting with arm
supported in abduction,
elbow flexed. Palpate
triceps tendon just above
olecranon, Tap directly on
tendon
❑ Response:
▪ Slight contraction of
elbow extensors
 EXAMINATION OF DEEP TENDON REFLEXES

❑ Myotatic Reflex:
▪ Hamstrings
▪ Tibial branch, sciatic nerve.
▪ (L5,S1,S2)
❑ Stimulus:
▪ Pt is prone with knee semiflexed
& supported. Palpate tendon at
the knee. Tap on finger or
directly on tendon.
❑ Response:
▪ Slight contraction of knee
flexors.
EXAMINATION OF DEEP TENDON REFLEXES

❑ Myotatic Reflex:
▪ Quadriceps (patellar, knee jerk)
▪ Femoral nerve (L2,L3,L4)
❑ Stimulus:
▪ Pt is sitting with knee flexed, foot
unsupported. Tap tendon of
quadriceps muscle between the
patella & tibial tuberosity.
❑ Response:
▪ Slight contraction of knee
extensors
 EXAMINATION OF DEEP TENDON REFLEXES

 Myotatic Reflex:
 Achilles (ankle jerk) Tibial (S1-S2)
 Stimulus:
 Pt is prone with foot over the end
of plinth or sitting with knee flexed
& foot held in slight dorsiflexion.
Tap tendon just above its insertion
on the calcaneus. Maintaining
slight tension on the
gastrocnemius-soleus group
improves the response.
 Response:
 Slight contraction of planterflexors
 SUPERFICIAL CUTANEOUS REFLEXES

❑ Superficial cutaneous reflexes are elicited with

a light stroke applied to the skin.

❑ The expected response is brief contraction of

muscles innervated by the same spinal
segments receiving the afferent inputs from
the cutaneous receptors
 EXAMINATION OF SUPERFICIAL CUTANEOUS
REFLEXES

❑ Superficial Reflex:
 Plantar (S1-S2)
❑ Stimulus:
 With blunt object (key or wooden end of
applicator stick(, stroke the lateral
aspect of the sole, moving from the heel
to the ball of the foot, curving medially
across the ball of the foot.
❑ Response:
 Normal response is flexion (PF) of the
great toe, & sometimes the other toes
(negative babinski’s sign)
 Abnormal response (positive babinski’s is
extension (DF) of great toe with fanning
of the four other toes (indicates UMN
lesions)
EXAMINATION OF SUPERFICIAL CUTANEOUS REFLEXES

❑ Superficial Reflex:
 Abdominal reflexes
 Above umbilicus= T8-T10
 Below umbilicus= T10-T12
❑ Stimulus:
 Position pt in supine, relaxed. Make brisk, light Abdominal Reflex
stroke over each quadrant of the abdominals
from the periphery to the umbilicus.
❑ Response:
 Localized contraction under the stimulus,
causing the umbilicus to move toward the
stimulus.
 Masked by obesity
 Absent in both UMN & LMN disorders
 REFRENCES

 O’Sullivan SB, Schmitz TJ, Physical Rehabilitation,

Fifth Edition, F.A. Davis Company, 2007; Ch.8; 227-
267

 A Guide to Neurological examination; Professor

Yasser Metwally, www.yassermetwally.com