Motor System Examination

General
• Five patterns of motor weakness
• Upper motor neuron
• Lower motor neuron
• Muscle disease
• Neuromuscular junction
• Functional weakness
Upper motor neuron
• Increase tone
• Increase reflexes
• Pyramidal pattern of weakness (weak extensors in the arm, weak
flexors in the leg)
Lower motor neuron
• Wastings
• Fasciculation
• Decreased tone
• Reduced or absent reflexes
Muscles disease
• Wasting
• Decreased tone
• Impaired or absent reflexes.
Neuromuscular junction
• Fatigable weakness
• Normal or decreased tone
• Normal reflexes
Functional weakness
• Normal tone
• Normal reflexes with out wasting
• Erratic power
Localizing the Lesion
• The level of the nervous system affected can be determined by the
distribution and pattern of the weakness
• Associated findings
Brain-stem signs
• All contralateral to the upper motor neuron weakness
• Third, fourth, sixth, and seventh lower motor neuron loss.
• Nystagmus and dysarthria
Hemisphere signs
• Aphasia
• Visual field defects
• Inattention or neglect
• Higher functional defecits
Mixed UMN and LMN lesion
• Motor neuron disease with normal sensation
• Combined cervical myelopathy and radiculopathy
• Lumbar radiculopathy with sensory abnormalities
Functional weakness
• The weakness not in a distribution that can be understood on an
anatomical basis
• The movement are very variables and power is erratic
• There is a difference between the apparent power of moving a limb
voluntarily and when power is being tested.
• No changes in tone or reflexes
What to do while examining
• Look at the position of the patient overall.
• Especially for a hemiplegic positioning, flexion of elbow and wrist with
extension of knee and ankle.
• Look for wasting.
• Compare the right with the left side.
• Look for fasciculation.
• Fasciculations are fine subcutaneous movements that represents contractions
of a motor unit.
What to do while examining
• Test for tone.
• Test muscle groups in a systematic way to test power.
• Test reflexes.
• Testing muscles of respiration and trunk muscles.
Important points to consider
• Describe what to do in simple terms.
• Demonstrate the movements you require.
• Test simple movements across single joints.
• Fix or hold the joint to isolate the movement you want to test.
• Allow the patient to move the joint through the full range before
testing power. When testing power, look at or feel the muscle
contract.
• Compare the strength of the right side with the left side
• Do not be afraid to repeat power tests so as to be certain of your
findings
• Think about what you are finding as you do the examination. It can be
useful to summarize what you find in your head as you do the
examination. This makes it easier when you come to write your
findings down in the notes (or report them to an examiner!).
Thank you