Examination of Motor System with reference.pptx

Examination of Motor System with reference for medical and applied medical students

1. Examination of Motor System Dr Shamshad Majmaah University 8/28/2024 1 Dr Shamshad Majmaah University

2. Objectives Identify the correct steps in clinical examination of the motor system. Examine the motor system systematically by inspection, palpation: checking of tone, power, reflexes (superficial and deep), coordination and gait. Reference: Hutchison's Clinical Methods; An Integrated Approach to Clinical Practice, 24th edition (2018), page 326-346. 8/28/2024 2 Dr Shamshad Majmaah University

3. Equipments required 8/28/2024 3 Dr Shamshad Majmaah University

4. Initial etiquettes Apply the principles of ethics, attitude and professionalism. Identify the patient and Greet. Introduce yourself to the patient. Apply hand hygiene. Explain the procedure and get verbal consent to perform. Conduct the examination as efficiently as possible 8/28/2024 4 Dr Shamshad Majmaah University

5. Pay attention to those areas with motor or reflex abnormalities. Compare symmetrical areas By compare on both sides. Position ( patient) :Comfortably seated / supine position Position ( Doctor): Stand on right side of patient. Expose part to be examined (don't over or underexpose the part). Ask if he/she is currently experiencing any weakness of limbs. 8/28/2024 5 Dr Shamshad Majmaah University

6. Inspection Wasting of muscles in upper and lower limbs. Fasciculation Posture Abnormal movements: Intentional tremors, pill rolling movements , Chorea, tics…... 8/28/2024 6 Dr Shamshad Majmaah University

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8. Examination Gait Romberg’s test Examination of upper limbs: Posture, wasting, fasciculation, tremor or other abnormal movements. Examination of lower limbs: Posture, wasting, fasciculation, tremor or other abnormal movements. 8/28/2024 8 Dr Shamshad Majmaah University

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10. Gait Ask the patient to walk 10 -20 feet, Turn and walk back the other way Response: Normal : Smooth and coordinated 8/28/2024 10 Dr Shamshad Majmaah University

11. Gait 8/28/2024 11 Dr Shamshad Majmaah University

12. Assess Tone/ Clonus Ask the patient: Let the arms/legs go loose & let me move them for you Muscle tone is 'the tension in the relaxed muscle' or 'the resistance, felt by the examiner during passive stretching of a joint when the muscles are at rest' Note: Normal Hypertonic: Increased tone: Rigidity/Spasticity Hypotonic: Flabby muscles 8/28/2024 12 Dr Shamshad Majmaah University

13. Normal 8/28/2024 13 Dr Shamshad Majmaah University

14. Assess Power of muscles The most commonly accepted way of assessing muscle power/strength is the Medical Research Council’s scale (MRC scale) of muscle power. This method involves the testing of key muscles in the upper and lower extremities. grade the power of specific muscle groups: Large joint muscles :(hip or knee joint) Individual muscles :muscles of hands / feet in relation to the movement of a single joint on a 0 to 5 scale accordingly. 8/28/2024 14 Dr Shamshad Majmaah University

15. Assess Tone/ Clonus Medical Research Council’s scale (MRC scale) of muscle power. Grade Muscle power Zero/N il No muscle contraction seen 1 Trace Flicker or trace of contraction seen 2 Poor Active movement only with gravity eliminated 3 Fair Active movement against gravity but no t resistance 4 Good Active movement against gravity but some resistance 5 Normal Active movement against gravity full resistance 8/28/2024 15 Dr Shamshad Majmaah University

16. Superficial Deep Plantar, Abdominal ,Cremastric, Corneal, conjunctival Muscle stretch reflexes/ Tendon reflexes, Reflexes 8/28/2024 16 Dr Shamshad Majmaah University

17. Reflex Process Response root level Jaw Ask the subject to partially open the mouth Place your finger firmly on the chin and tap briskly Closure of the jaw Vth Cranial N 8/28/2024 17 Dr Shamshad Majmaah University

18. Reflex Process Response Spinal cord root level Biceps Ask the subject to flex the elbow at right angle in semiprone position Place your thumb or index finger on the Bisceps tendon Contraction of Bisceps C5,6 Musulocutaneous N Triceps Ask the subject to flex elbow and rest the forearm across the chest Tap briskly on tendon Contraction of triceps C6,7,8 Radial N Supinator/ Brachiradialis Ask the subject to flex the elbow at right angle in semiprone position Tap briskly upon styloid process of radius Contraction of BR muscle and supination of elbow C5,6 Radial N 8/28/2024 18 Dr Shamshad Majmaah University

19. Reflex Process Response root level Knee/ Patellar Ask the subject to be supine or sit with legs near edge of bed hanging freely or one leg crossed over other Tap the patellar tendon briskly Extension of leg Contraction of quadriceps muscle L2-4 Femoral N Ankle/ Achilles Ask the subject stand and place the leg In everted position . Slightly dorsiflex the foot and tap the achilles tendon briskly Contraction of calf muscle S1-2 Tibial N 8/28/2024 19 Dr Shamshad Majmaah University

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22. Jendrassik or reinforcement manoeuvre : Importance: Used to augment hypoactive reflexes Technique: Subject is asked to lock the hands and pull forcefully apart Or Ask the subject to clinch the teeth with force Dr. Erno Jendrassik 8/28/2024 22 Dr Shamshad Majmaah University

23. Grade 0-4 Reflex Right Left Biceps Triceps Supinator/ Brachiradialis Knee Ankle Jaw Inference : Report : 8/28/2024 23 Dr Shamshad Majmaah University

24. Clinical Significance of reflexes Assess the integrity of the motor system Decreased LMN lesion Peripheral nerve lesions, entrapment , monoeuropathy Diabetes Mellitus, Hypothyroidism, Muscle diseases Spinal cord injury with spinal shock, Cerebellar diseases Bilateral absent of ankle jerk in cauda equina syndrome 8/28/2024 24 Dr Shamshad Majmaah University

25. Significance Increased Lesion injury involving UMN (Brain ,brain stem, spinal cord) Severe chronic cases clonus with spasticity present Common in stroke, spinal cord injury, cerebral palsy, multiple sclerosis Clinical Significance of reflexes 8/28/2024 25 Dr Shamshad Majmaah University

26. Romberg test Ask the patient to stand with his/her feet together and then close the eyes. Observe t he patient if he /she can balance and maintain with the eyes closed. The Romberg test is positive if the patient falls to one side. Falling to one side implies dysfunction of one of these balance systems. [three systems are routinely used to maintain balance: proprioception, the vestibular apparatus and vision.] Eye closure removes visual cues for maintaining balance. In cerebellum lesion the Romberg test can only be performed if the patient is able to stand well with feet together and eyes open. 8/28/2024 26 Dr Shamshad Majmaah University

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28. Test for coordination Finger-nose-finger test Rapid alternating movement of one hand over the other ( dysdiadochokinesia ) Heel-shin test 8/28/2024 28 Dr Shamshad Majmaah University

29. II: Limb Coordination: A ssessed in both the arms and legs 1: Finger-to-Nose Test : The patient is asked to touch his/her nose with the index finger, then the examiner's finger, and then his/her nose again. Speed, accuracy and any tremor are noted . 2: Heel-to-Shin Test: The heel of one leg is run smoothly down the other shin, and speed, accuracy and any tremor are noted. 3: Rapid Alternating Movements ( Diadochokinesia ): The patient is asked to alternately slap the thigh with the front and back of the hand, or to touch each finger to the thumb. Each side is tested separately and compared with the other. Foot tapping is a rapid alternating movement frequently evaluated in the lower extremity. 8/28/2024 29 Dr Shamshad Majmaah University

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31. Ataxia and dysmetria are general terms used to describe unevenness in the performance of any of the above tests, and are frequently due to lesions involving the cerebellar hemispheres. Cerebellar lesions produce ataxia on the side ipsilateral to the lesion. Upper motor neuron lesions or sensory lesions that result in altered proprioception can also result in ataxia and dysmetria. 8/28/2024 31 Dr Shamshad Majmaah University

32. III: Ability to Check Movements: to evaluated by asking the patient to maintain flexion of his/her arm at the elbow against resistance provided by the examiner. The examiner then abruptly lets go of the patient's arm and observes the ability of the patient to “check” or break the flexion movement. An inability to check movements can be seen with lesions of the ipsilateral cerebellar hemisphere, also in severe sensory disturbances causing altered proprioception. 8/28/2024 32 Dr Shamshad Majmaah University

33. IV: Vestibular Coordination 1: Past pointing and compass turning evaluate the integrity of the vestibular system. 1: Past pointing : The patient is asked to repeatedly elevate his/her arm vertically and then return to the horizontal such that the index finger touches the examiner's finger that is held directly in front of the patient. This is performed with the eyes open initially, and closed later on. A drift of the patient's arm in one direction is strongly suggestive of a lesion involving the ipsilateral vestibular apparatus. 2: Compass Turning: The patient is asked to march in place with the eyes closed. Rotation of the body in one direction is suggestive of ipsilateral vestibular pathology. 8/28/2024 1 Dr Shamshad Majmaah University