The Neurological Examination


Part II – Motor System Examination and Coordination

Dante P. Bornales, MD, MHPEd Fellow of the Philippine Neurological Association

The Neurological Examination

Always include the following in the Motor System examination: General Inspection of the Motor System Muscle tone Muscle Strength – Manual Muscle Testing Coordination

Your task: recall UMN and LMN lesions and signs

Inspection
When inspecting, look for: 6. Wasting/Atrophy - a reduction of the muscle bulk in certain muscles compared with other muscle groups - wasted muscles are frequently weak

Always compare the symmetry of muscles!

Observe! muscle atrophy of the thenar muscle of the left hand

Inspection
When inspecting, look for: 2. Body position/s 3. Scars - may indicate previous injury/ies or surgery, which may have affected a nerve or the muscle itself

Inspection
When inspecting, look for: 4. Fasciculations - seen as rippling or twitching of muscles at rest

5. Involuntary movements - look for jerks, tremors, dystonia, other dyskinesias - describe the abnormal movements

Whenever possible, always check for the patient’s “gait”
1. ask the patient to walk in his usual fashion, with arms on the side 2. observe for patient’s posture, the pattern of the arm and leg movements, and the control of the trunk 3. if normal, ask: heel-toe walk stand on his toes and heels without support hop! (most patients with significant weakness cannot hop)

Muscle Tone Tone – “how floppy or stiff a limb feels”

Some patients may have difficulty relaxing during the exam, which can artificially increase stiffness in their limbs. Always do your utmost effort to put them at ease!

Testing for muscle tone

Testing for muscle strength

MRC Scale for grading muscle strength
0 1 2 3 4 5 No movement Flicker of muscle when pt. tries to move Moves, gravity eliminated Moves against gravity but not against resistance Moves against resistance but not to full strength Full strength (cannot overcome the movement)

Testing for shoulder adduction and abduction

Testing for flexion (C5-C6 – biceps) and extension ((C6-8) at the elbow

Testing for extension at the wrist (C6-8, radial nerve)

Testing for extension and flexion at the wrist

Testing for hand grip (C7-8, T1)

Testing for finger abduction (C8-T1, ulnar nerve)

Testing for opposition of the thumb ( C8, T1, median nerve)

Testing for flexion at the hip L2-4, iliopsoas)

Testing for extension at the hips (S1, gluteus maximus)

Testing for adduction (L2-4, adductors) and abduction (L4-5, S1, Gluteus maximus and medius) at the hips

Testing for flexion at the knee (L4-5, S1-2, hamstrings

Always remember to compare the symmetry of both sides

Testing for extension at the knee (L2-4, quadriceps)

Variation (sitting) in testing for the hip flexion

Variation (sitting) in testing for knee extension

Variation in the position to test for knee flexion

Testing for dorsiflexion (L4-5) and plantar flexion (S1)

End of segment

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