Motor system examination

Neurological examination - Motor system

1. Motor System Examination Dr. Ahmed Koriesh

2. Examination of motor system: Inspection Muscle Tone Muscle Power Reflexes

3. 1) Inspection Muscle state Fasciculation Abnormal movements Skeletal deformities Trophic changes

4. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Examination : Examiner stand central Compare between both sides Compare between distal & Proximal Measurement: use measurement tape to measure muscle Determine the most bulky part of the muscle Measure its distance from a fixed bony prominence Measure the circumference using a measurement tape In the other side, measure the circumference at the same distance from the bony prominence.

5. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Hypertrophy: Causes : - True hypertrophy (with increased muscle power) - Pseudohypertrophy (without increased muscle power) as in: Duchenne muscle dystrophy Becker muscle dystrophy Myotonia congenita Acromegaly

6. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Hypertrophy:

7. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Hypertrophy:

8. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Wasting: Signs : Prominence of bony prominence

9. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Wasting: Signs : Prominence of bony prominence

10. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Wasting: Signs : Prominence of bony prominence Shiny shaft of tibia

11. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Wasting: Signs : Prominence of bony prominence Shiny shaft of tibia Examples: Single nerve lesion Neuropathy  bilateral symmetrical distal, LL > UL Myopathy  bilateral symmetrical proximal (usually)

12. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Wasting:

13. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Abnormal Muscle state : 1- Wasting:

14. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Fasciculation: Spontaneous contraction of a group of muscles fibers It is visible for the doctor & perceived by the patient Causes: Physiological: with fatigue, anxiety, caffeine Pathological: “irritation of AHC” Motor neurone disease Cervical spondylosis Poliomyelitis

15. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Fasciculation: How to elicit: Tapping the muscle Where to look for: Deltoid Pectoralis major Quadriceps

16. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Fasciculation:

17. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Fibrillation: Spontaneous contraction of a single muscle fiber Seen only in the tongue Indicate AHC irritation

18. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Tremors Chorea Dystonia Ballismus Athetosis

19. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Pes Cavus: exaggerated arch of the foot Congenital: short big toe & hammer toe Acquired: big toe larger than adjacent one

20. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Pes Cavus: exaggerated arch of the foot Congenital: short big toe & hammer toe Acquired: big toe larger than adjacent one Value: point to hereditary disorders Scoliosis Kyphosis Lordosis

21. 1) Inspection Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Due to loss of trophic impulses from AHC and loss of muscle tone. Trophic ulcers Coldness Dry skin Loss of hair

22. 2 ) Muscle Tone Mechanism Hypotonia Hypertonia Examination Muscle tone: resistance to passive movements

23. 2 ) Muscle Tone Mechanism Hypotonia Hypertonia Examination Causes: LMNL : injury to AHC, Root, Nerve, Muscle UMNL: shock stage Cerebellar ataxia

24. 2 ) Muscle Tone Mechanism Hypotonia Hypertonia Examination Causes: Pyramidal Lesion: “Spasticity” Affect antigravity muscles (flexors of upper limbs, extensors of lower limb) Clasp Knife (initial resistance suddenly released) Extrapyramidal Lesion: “Rigidity” Affect flexors more than extensors Lead pipe: continuous resistance through the movement Cog wheal:  a combination of lead pipe rigidity and tremor which presents as a jerky resistance to passive movement 

25. 2 ) Muscle Tone Mechanism Hypotonia Hypertonia Examination 1- Passive flexion & extension: P atient must be calm, relaxed Grasp patient from bony prominence, don’t grasp the muscle. Use all range of movements Compare both sides

26. 2 ) Muscle Tone Mechanism Hypotonia Hypertonia Examination 2- Shaking method: Used for distal joints (wrist & ankle) Catch the upper limb from the styloid process of radius and ulna Shake wrist from side to side and from front backwards 3- Gower method: Used only for shoulder joint Stand behind the patient, put your hands in the axilla and try to hold the patient. Slipping of the arms indicate hypotonia

27. 2 ) Muscle Tone Mechanism Hypotonia Hypertonia Examination N.B: Paratonia “gegenhalten”: Resistance of the patient to passive movement. Occur in cortical brain disorders as dementia How to differentiate from spasticity: No pyramidal signs, no clasp knife How to differentiate from Rigidity: The faster the movement the more the resistance

28. 3) Muscle Power MRC Grades Types of Weakness Examination Grade 5 : Muscle contracts normally against full resistance. Grade 4 : Muscle strength is reduced but muscle contraction can still move against resistance. Grade 3 : Muscle strength is further reduced such that the joint can be moved only against gravity with the examiner's resistance completely removed. Grade 2 : Muscle can move only if the resistance of gravity is removed. As an example, the elbow can be fully flexed only if the arm is maintained in a horizontal plane. Grade 1 : Only a trace or flicker of movement Grade 0: No movement is observed.

29. 3) Muscle Power MRC Grades Types of Weakness Examination UMNL: Weakness affect progravity muscles more than antigravity muscles, extensors of the upper limb and flexors of the lower limbs. LMNL : Varies according to the disorder: Peripheral neuropathy: Distal, bilateral, symmetrical Myopathy: Proximal, bilateral symetrical Myasthenia: Descending weakness GBS: Ascending weakness

30. 3) Muscle Power MRC Grades Types of Weakness Examination Fix the proximal joint Grasp the patient from bony prominence to avoid interfering with muscle contraction Ask patient to move his joint against your resistance Compare both sides

31. 3) Muscle Power MRC Grades Types of Weakness Examination Shoulder : Flexion: Extension: Adduction: Abduction: Elbow: Flexion: Extension: Wrist: Flexion: Extension: Hand:

32. 3) Muscle Power MRC Grades Types of Weakness Examination Hand: Thenar: Extension: Ext Pol Longus & Brevis (radial) Flexion: Flex Pol (median) Abduction: Abd Pol Longus (radial) & Brevis (median) Adduction: add Pol (ulnar) All thenar muscle are supplied by Median nerve except Adductor policis by Ulnar. Hypothenar: Abduction: Abd Digiti minim (ulnar) Hypothenar muscle supplied by ulnar nerve Opponens : all supplied by Median nerve Interossei: all supplied by ulnar (dorsal & palmer) Lumricals : 1 st & 2 nd (Median), 3 rd & 4 th (Ulnar)

33. 3) Muscle Power MRC Grades Types of Weakness Examination Hip: Flexion Extension Abduction Adduction Knee : Flexion Extension Ankle : Dorsiflexion Planter flexion