1. Motor and Sensory
Examination
Dr Rahul Awasthi
Neurosurgery department
SAIMS
2. ASSESSMENT OF MOTOR SYSTEM :
• INSPECTION AND PALPATION OF MUSCLES
• ASSESSMENT OF TONES
• EXAMINATION OF REFLEXES
• TESTING MOVEMENT AND POWER
• CO-ORDINATION
3. INSPECTION AND PALPATION OF
MUSCLES
- Requires full exposure of muscles.
- Look for asymmetry, inspecting both
proximally and distally.
- Note any deformities.
- Examine specially for wasting or hypertrophy,
fasciculation and involuntary movement.
- Palpate muscles to assess their bulk.
5. Common abnormalities
• 1. Muscle bulk :
• Lower motor neuron lesions cause wasting in
specific muscles.
• Upper motor neuron damage can cause
disuse atrophy of muscle groups.
• Certain occupation and sports leads to muscle
hypertrophy.
• The wasting of muscle is associated with
diseases like rheumatoid arthritis, cachexia.
6. 2.Fasciculation: Looks likes irregular twitches
under the skin overlying muscles at rest
commonly seen in LMN lesions.
3.Myclonic jerk: It is the sudden shock like
contractions of one or more muscles. -
Associated with epilepsy, diffuse brain damage
and dementias .
7. 4. Tremor:
is oscillatory movement about a joint or a
group of joints resulting from alternating
contraction and relaxation of muscles.
• Common Types
i. Physiological tremor :- hyperthyroidism,
alcoholism.
ii. Coarse tremor (slow) :-Parkinson's disease.
iii. Intention tremor :- Cerebellar damage.
8. ASSESSMENT OF TONES
Tone:
is the resistance felt by the examiner when
moving a joint passively through its range of
movement.
• Site to check the tone:
• Upper Extremities - wrist and elbow joint
• Lower Extremities - knee level, ankle joint.
• Common abnormalities: Muscle tone may be
decreased (Hypotonia) or increased (hypertonia).
9. • Hypotonia :
is decreased tone and usually associated with
muscle wasting, weakness and hyporeflexia.
• Cause : breach in the reflex arc,cerebellar
disease, spinal shock.
• Hypertonia : There are two principal types
hypertonia
1.Spasticity
2.Rigidity
10. Spasticity : means increased tone throughout
range of motion, and then there is a sudden
release (catch): so called ‘clasp knife effect ‘
• Seen in UMN lesion, pyramidal pathway
lesion.
• In second type, there is equal resistance in
both agonist and antagonists at any point: so
called ‘ plastic or lead-pipe rigidity’.
• Seen in extra-pyramidal system.
• Spasticity is velocity dependent(sudden
release).
11. • Rigidity : increased tone throughout the
range of motion.
• The agonist and antagonist contract
alternately, rapidly : so called ‘cog-wheel rigidity’.
• seen in extra pyramidal diseases such as
Parkinson’s disease.
• Rigidity is not velocity dependent
(continuous) .
15. CREMASTERIC REFLEX(L1-2) :
• Abduct and externally rotate the patient's medial
aspect of the thigh.
• Stick the upper medial aspect of the thigh.
• Normally the testicle on the side stimulated will
rise briskly.
• Used to identify the level of spinal cord lesion
after injury.
16. • 2. DEEP TENDON REFLEXES :- Rapid muscle
contraction response when deep receptors in
the muscle or in the tendons are stimulated.
• 1. Hoffman's Reflex : - The test involves
tapping the nail or flicking the terminal
phalanx of the middle or ring finger.
• A positive response is seen with flexion of the
terminal phalanx of the thumb
• 2. Finger jerk : - Place your middle and index
fingers across the palmer surface of patient's
proximal phalanges. - Observe the flexion of
the patient's finger
18. Supinator jerk: strike the lower end of the
radius about 5 cm above the wrist
• Segmental innervation C 5-6
• Contraction of brachioradialis and flexion of
the elbow
• The biceps often contracts as well slight
flexion of the fingers may occur.
19. Triceps jerk (C6,7) - Extension at the
elbow when the triceps tendon is
strike
20. Knee jerk reflex (L3,L4) - Extension at
the knee when the patellar tendon is
strike.
21. Ankle reflex (S1,2) - Plantar flexion at
the foot a when Achilles tendon is
strike
22. TESTING MOVEMENT AND POWER
Muscle power.
• 0. No muscles contraction visible.
• 1. Flicker of contraction but no movement.
• 2. Joint movement when effect of gravity
eliminated.
• 3. Movement against gravity but not against
examiner's resistance.
• 4. Movement against resistance but weaker than
normal.
• 5. Normal power.
23.
24. General examination principles
• Power
– Use power scale
– Test two movements at each joint (agonist and
antagonist)
– Always compare left with right at each level
– Work from proximal to distal
25. • Paralysis : refers to weakness or loss of voluntary
movement.
• 1)Monoplegia: a paralysis of one extremity only
• 2)Paraplegia:a symmetric paralysis of both
extremities
• 3)Quadriplegia : a paralysis of all 4 extremities
• 4)Hemiplegia: a paralysis of one side of the body
limited by the median line
• 5)Crossed paralysis: a paralysis of one or more
ipsilateral cranial nerves and contralateral
hemiplegia.
26. • Based on the location, paralysis may be
classified as:
• 1)Neurogenic paralysis: caused by lesion of
motor neurons or peripheral nerves
• 2)Myogenic paralysis: caused by muscular
diseases
27. • The ultimate goal of strength testing is to
decide whether there is true "neurogenic"
weakness.
• To determine which muscles/movements are
affected.
• Probably the most important decision is
whether the weakness is due to damage to
upper or lower motor neurons (UMN or LMN)
28. • UMN weakness is due to damage to the
descending motor tracts (especially
corticospinal)
• Anywhere in its course from the cerebral
cortex through the brain stem and spinal cord.
• UMN weakness is typically associated with
increased reflexes and a spastic type of
increased tone.
29. • LMN weakness is due to damage of the
anterior horn cells or their axons (found in the
peripheral nerves and nerve roots).
• This results in decreased stretch reflexes in the
affected muscles and decreased muscle tone.
• Additionally, atrophy usually becomes
prominent after the first week or two.
30. The Neurological Examination
Motor Examination
Upper Motor Neuron Lower Motor Neuron
Strength
Tone Spasticity Hypotonia
DTR’s Brisk DTR’s Diminished or
Absent DTR’s
Plantar Responses Upgoing Toes Downgoing Toes
Atrophy/Fasiculations None +/-
31. Co-ordination:
Examination to detect complex movements
smoothly and efficiently.
• a. Rebound phenomenon
• b. Finger-nose test
• c. Heel-shin test
• d. Rapid alternating movements
Apraxia: It is difficulty or inability to perform a
motor action despite the patient understanding
the task.
32. • Rebound test: Ask the patient to flex at the
elbow and resist you as you try to extend the
arm.
• Place your other hand on the patients
shoulder and turn the patient’s head toward
the other direction, to shield the patient’s face
and eyes.
• Let the arm go suddenly.
• Arm returns to steadying position—normal.
• Arm oscillates several time then stays—
abnormal rebound.
33. • Rapid alternating movements : Demonstrate
to the patient (finger tapping, hand tapping,
etc.), first in slow motion, and then faster.
• If the patient is able to do the task with
normal rate and rhythm—normal.
• If movements are irregular, disorganized,
dysrhythmic, uncoordinated—
dysdiadochokinesia
34. • Heel-to-shin test : Done in the supine
position.
• Ask the patient to lift one leg up and place the
heel on the shin of the other leg, and then
smoothly rub it along the shin down toward
the toes.
• The test is abnormal if movement is irregular
or the heel falls off the leg.
35. • Finger-nose test :
• Ask the patient to touch your finger with his or
her index finger, then to the tip of the nose.
• You may move your target finger in different
directions.
• Do one arm at a time.
• 1. Patient accurately performs the task: normal.
• 2. Patient develops tremor when approaching the
target (your finger or his nose)—intention
tremor: cerebellar disease.
• 3. Patient misses the target: past-pointing or
dysmetria
37. Neural Pathways
• Sensory impulses travel to the brain via
– Two ascending neural pathways
1. Spinothalamic tract
2. Posterior columns
• Impulses originate in the afferent fibers of
the peripheral nerves, are carried through
the posterior dorsal root into the spinal
cord.
40. Assessment
• Scatter stimuli over the distal and proximal
parts of all extremities and trunk to cover
most of the dermatomes.
• Abnormal symptoms may indicate need to test
the entire body surface
– Pain
– Numbness
– Tingling
41. • Compare sensations on symmetric parts of the
body
• If decrease in sensation
– Systematic testing
– From point of decreased sensation toward
sensitive area
– Note where sensation changes
42. • Dermatones
– C3- front of neck
– T4 - nipples
– T10 – umbilicus
– C6 – thumb
– L1 inguinal
• L4 – Knee
• L5 – Anterior ankle & foot
Dermatone = skin innervated by the sensory root
of a single spinal nerve
43.
44. Dermatomes
• Important ones you should
remember:
• T4 – level of nipples
• T10 – level of umbilicus
• S1 – sole of foot
• Also know upper and lower
limb
45. Light Touch Sensation
• Use wisp of cotton
• Ask clients to close both eyes and tell you what
they feel and where
• Examine the spinal segments sequentially (e.g.
in the upper limb start on the outer border of
the arm (C5), then proceed downwards to the
lateral border of the forearm and thumb (C6),
index finger (C7).
• Normal Findings
Correctly identifies light touch
46. Abnormal findings
– Peripheral neuropathies due to:
• Diabetes
• Folic acid deficiencies
• Alcoholism
– Lesions of the ascending spinal cord, brain stem,
cranial nerves, and cerebral cortex
48. Pain Sensation
• Establishing a baseline for sharpness (e.g.
sternal area) before examining the limb.
• Test pin prick sensation down each limb and
over the trunk.
• Ask the patient to report if the quality of
sensation changes. Either becoming blunter
(hyperesthesia).
49. • Test each dermatome in turn, but also bear in
mind peripheral nerve distribution.
• Map out the boundaries of any abnormal
area.
50. Abnormalities to pain
• Analgesia = absence of pain sensation
• Hypoalgesia = decreased
• Hyperalgesia = increased
51. Temperature
• Only tested when pain sensation is abnormal.
– Temp. & pain travel in the lateral spinothalamic
tract
• Test tubes, hot & cold H2O
52. Vibration
• Low pitched tuning fork (128Hz)
• Distal interphalangeal joint (finger & big toe)
• Ask what the patient feels.
• Ask to tell when the vibration stops and then
touch the fork to stop it.
• If impaired- proceed to more proximal joints
or bony prominances.
53. Posterior Column Tract
• Vibration – often first sense to be lost in
peripheral neuropathy.
• Loss = posterior column disease, lesion of
peripheral nerve or root
54. Position ( Kinesthesia)
• Passive movement of extremity
• Finger or big toe up and down
• Hold by sides b/t thumb and index finger
• If position sense is impaired, move proximally
to next joint
55. Tactile Discrimination
• Sensory cortex
• Eyes closed during testing
• Stereognosis= identification of an object by
feel
– Astereognosis, inability to recognize objects
56. • Number identification= Graphesthesia
– Used when stereognosis prevented due to motor
impairment for ex. In arthritis
– Use blunt end of pen/pencil to draw number
• Two-point discrimination
– Alternate double with single stimulus
– Minimal distance1 from 2 points= less than 5mm
on finger pads
57. Charting
• If normal
– Identifies light touch, dull and sharp sensations to
trunk and extremities.
– Vibratory sensation, stereognosis, graphesthesia,
two-point discrimination intact.
58. • Abnormal results in these tests indicate
lesions of the sensory cortex.
• These tests not done on children 6 yrs and
younger.
• 65yrs &older
– loss of sensation of vibration at the ankle
– Position sense in big toe may be lost
– Tactile sensation impaired
59. INFANTS
• Little sensory testing
• Hypoesthesia
• Responds to pain by crying
• General reflex withdrawal of all limbs
