Examination of motor system

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1. MOTOR SYSTEM EXAMINATION Physiology department Dr. Dina Merzeban 2. ANATOMY AND PHYSIOLOGY 3. MOTOR PATHWAYS Corticobulbar (corticonuclear) fibers: originate in the…
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  • 1. MOTOR SYSTEM EXAMINATION Physiology department Dr. Dina Merzeban
  • 2. ANATOMY AND PHYSIOLOGY
  • 3. MOTOR PATHWAYS Corticobulbar (corticonuclear) fibers: originate in the region of the sensorimotor cortex, where the face is represented. They pass through the posterior limb of the internal capsule and the middle portion of the crus cerebri to their targets, the somatic and brachial efferent nuclei in the brain stem.
  • 4. Corticospinal tract: originates in the remainder of the sensorimotor cortex and other cortical areas. It follows a similar trajectory through the brain stem and then passes through the pyramids of the medulla (hence, the name pyramidal tract), decussates, and descends in the lateral column of the spinal cord.
  • 5. EXAMINATION OF MOTOR SYSTEM Inspection MuscleTone Musclepower Reflexes
  • 6. 1) INSPECTION Muscle state Fasciculation Abnormal movements Skeletal deformities Trophic changes
  • 7. 1) INSPECTION Muscle state Fasciculation Abnormal movement Skeletal deformities Trophic changes Examination: Examiner stand central Compare between both sides Compare between distal & Proximal
  • 8. 1) INSPECTION Muscle state Abnormal Muscle state: 1- Hypertrophy: Causes: - True hypertrophy (with increased muscle power) - Pseudohypertrophy (without increased muscle power) as Duchenne muscle dystrophy Becker muscledystrophy Myotonia congenita Acromegaly
  • 9. 1) INSPECTION Muscle state Abnormal Muscle state: 1- Hypertrophy:
  • 10. 1) INSPECTION Muscle state Abnormal Muscle state: 1- Wasting: Signs: Prominence of bonyprominence
  • 11. 1) INSPECTION Muscle state Abnormal Muscle state: 1- Wasting: Signs: Prominence of bonyprominence Shiny shaft oftibia
  • 12. 1) INSPECTION Muscle state Abnormal Muscle state: 1- Wasting: Examples: Single nerve lesion Neuropathy  bilateral symmetrical distal, LL > UL Myopathy  bilateral symmetrical proximal (usually)
  • 13. 1) INSPECTION Fasciculation: Spontaneous contraction of a group of muscles fibers It is visible for the doctor & perceived by thepatient Causes: Physiological: with fatigue, anxiety, caffeine Pathological: “irritation ofAHC” Motor neuronedisease Cervicalspondylosis Poliomyelitis
  • 14. 1) INSPECTION Fasciculation: How to elicit: Tapping themuscle Where to look for: Deltoid Pectoralis major Quadriceps
  • 15. 1) INSPECTION Fasciculation:
  • 16. 1) INSPECTION Fibrillation: Spontaneous contraction of a single muscle fiber Seen only in thetongue Indicate AHC irritation
  • 17. 1) INSPECTION Abnormal movement Tremors Chorea Dystonia Ballismus Athetosis
  • 18. 1) INSPECTION Skeletal deformities Pes Cavus: exaggerated arch of the foot Congenital: short big toe & hammertoe Acquired: big toe larger than adjacentone
  • 19. 1) INSPECTION Skeletal deformities Pes Cavus: exaggerated arch of the foot Congenital: short big toe & hammertoe Acquired: big toe larger than adjacentone Value: point to hereditary disorders Scoliosis Kyphosis Lordosis
  • 20. 1) INSPECTION trophic changes: Due to loss of trophic impulses from AHC and loss of muscle tone Trophic ulcers Dry skin Loss of hair
  • 21. 2) MUSCLE TONE Mechanism Muscle tone: resistance to passive movements
  • 22. 2) MUSCLE TONE  hypotonia Causes: LMNL: injury to AHC, Root, Nerve, Muscle UMNL: shock stage Cerebellar ataxia
  • 23. 2) MUSCLE TONE - HYPERTONIA 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
  • 24. 2) EXAMINATION OF MUSCLE TONE 1- Passive flexion & extension: Patient must be calm, relaxed Grasp patient from bony prominence, don’t grasp the muscle. Use all range of movements Compare both sides
  • 25. 2) EXAMINATION OF MUSCLE TONE 2- Shaking method: Used for distal joints (wrist & ankle) Catch the upper limb from the styloid process of radius andulna Shake wrist from side to side and from frontbackwards 3- Gower method: Used only for shoulderjoint Stand behind the patient, put your hands in the axilla and tryto hold the patient. Slipping of the arms indicate hypotonia
  • 26. 3) MUSCLE POWER MRC Grades 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.
  • 27. MRC SCALE FOR GRADING MUSCLE POWER Grade 0 Complete paralysis Grade 1 A flicker of contraction only Grade 2 Power detectable only when gravity is excluded by postural adjustment Grade 3 Limb can be held against gravity but not resistance Grade 4 Limb can be held against gravity and some resistance Grade 5 Normal power
  • 28. 3) MUSCLE POWER Types of Weakness 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
  • 29. 3) EXAMINATION OF MUSCLE POWER 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
  • 30. 3) EXAMINATION OF MUSCLE POWER Shoulder: Flexion: Extension: Adduction: Abduction: Elbow: Flexion: Extension: Wrist: Flexion: Extension: Hand:
  • 31. 3) EXAMINATION OF MUSCLE POWER 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: 1st & 2nd (Median), 3rd & 4th (Ulnar)
  • 32. 3) EXAMINATION OF MUSCLE POWER Examination Hip: Flexion Extension Abduction Adduction Knee: Flexion Extension Ankle: Dorsiflexion Planter flexion
  • 33. DELTOID •Main Segmental Supply - C5 •Peripheral Nerve – Circumflex •Action: Shoulder abduction, extension •Test: The patient abducts arms with elbows bent. Press down on the upper arms
  • 34. DELTOID
  • 35. INFRASPINATUS (C5, Suprascapular) •Action: Shoulder External rotation •Test: The patient rests the arm down by his side with the forearm pointing anteriorly at 90° to the arm. Resist external rotation of the shoulder
  • 36. PECTORALIS MAJOR (sternocostal head) •Nerve supply: Medial and lateral pectoral; C6, C7, C8 •Causes shoulder adduction •Test: The patient brings the arm just a little away from the side. Hold at th elbow and resist shoulder adduction. Observe the musclecontract on the anterior chest wall
  • 37. PECTORALIS MAJOR (Clavicular head) •Nerve Supply: Lateral pectoral N.; C5, C6 •Shoulder flexion •The patient brings the arm up laterally with the forearm pointing superiorly. Hold at the elbow and resist shoulder flexion forwards.
  • 38. RHOMBOIDS •Nerve Supply: Dorsal scapular N.; C4, C5 •Shoulder internal rotation •Test: The patient brings the hand to the small of the back with the palm facing posteriorly. Press against the elbow of the patient's hand to resist movement of the elbow posteriorly.
  • 39. SERRATUS ANTERIOR •Long thoracic C5, C6, C7 •Stabilization of scapula •Test: The patient brings the hands anteriorly to push against a vertical wall. In paralysis, the free medial edge of the scapula 'wings„ posteriorly away from the rib cage Winging of scapula
  • 40. LATISSIMUS DORSI •Thoracodorsal N.; C6, C7, C8 •Shoulder adduction •The patient brings the arm up laterally to horizontal. Hold at the elbow and resist shoulder adduction. Observe the muscle contract on the side of the chest wall
  • 41. ELBOW Biceps brachii •Musculocutaneous N.; C5, C6 •Elbow flexion •The patient flexes the elbow with the forearm supinated. Hold the wrist, stabilize at the elbow and resist flexion
  • 42. TRICEPS •Radial N.; C6, C7, C8 •Elbow extension • The patient holds the arm out with the elbow half-extended. Hold at the wrist, stabilize at the elbow and resist extension Testing Long head Testing whole muscle
  • 43. BRACHIORADIALIS •Radial N.; C5, C6 •Elbow flexion •The patient flexes the elbow with the forearm mid-pronated. Hold the wrist, stabilize at the elbow and resist flexion. Observe the muscle belly along forearm.
  • 44. FOREARM: SUPINATOR •Radial N.; C6, C7 •Forearm supination •Grasp the patient in a handshake with the patient's elbow extended and resist supination.
  • 45. PRONATOR TERES •Median N.; C6, C7 •Forearm pronation •Grasp patient in a handshake with his elbow extended and resist pronation.
  • 46. WRIST AND HAND Extensor carpi radialis longus •Radial N.; C5, C6 •Wrist extension and abduction •The patient cocks the wrist up. Press over the dorsum of the hand at the second metacarpal head and resist extension and abduction of the wrist. Stabilize with the other hand at the base of the forearm near the wrist
  • 47. EXTENSOR CARPI ULNARIS •Posterior interosseous N.; C7, C8 •Wrist extension and adduction •The patient cocks the wrist up. Press over the dorsum of the hand at the fifth metacarpal head and resist extension and adduction of the wrist. Stabilize with your other hand at the base of the forearm near the wrist.
  • 48. FLEXOR CARPI RADIALIS •Median N.; C6, C7 •Wrist flexion and abduction •Hold the fingers of your hand against the upturned palmar aspect of the patient's second metacarpal head and resist wrist flexion and abduction, stabilizing at the dorsal forearm with your other hand. Observe the flexor tendon at the wrist
  • 49. FLEXOR CARPI ULNARIS •Ulnar N.; C7, C8, T1 •Wrist flexion and adduction •Hold the fingers of your hand against the patient's upturned hand at the hypothenar eminence and resist wrist flexion and adduction, stabilizing at the dorsal forearm. Observe the tendon over the ulnar border of the wrist.
  • 50. FLEXOR DIGITORUM LONGUS •Median N; C7, C8, T1 •Causes Finger flexion •Stabilize the patient's proximal phalanx between your thumb and finger and use a finger of your other hand to resist flexion of the proximal inter- phalangeal joint
  • 51. FLEXOR DIGITORUM PROFUNDUS I, II •Anterior interosseous N.; C7, C8 •Finger flexion •Stabilize the patient's index middle phalanx between your thumb and finger and resist finger flexion by pulling against the flexed distal phalanx.
  • 52. FLEXOR DIGITORUM PROFUNDUS III, IV •Ulnar N.; C7, C8 •Finger flexion •As for Flexor digitorum profundus I, II, but with the patient's little finger
  • 53. FLEXOR POLLICIS LONGUS •Anterior interosseous N.; C7, C8 •Thumb flexion •The patient flexes the thumb at the inter- phalangeal joint. Press against the distal phalanx and resist flexion at this joint.
  • 54. ABDUCTOR POLLICIS BREVIS •Median N.; C8, T1 •Thumb abduction •The patient holds the palm upward and brings his thumb away from his hand at 90° to the palm. Hold your thumb against the side of the patient's thumb and resist abduction. Observe the thenar eminence.
  • 55. OPPONENS POLLICIS •Median N •Opposition of the thumb •The patient should try to touch the tip of the little finger with the thumb, against your resistance.
  • 56. FIRST DORSAL INTEROSSEOUS •Ulnar N.; C8, T1 •Index finger abduction •The patient holds the hand out palm downwards with the fingers apart. Hold your finger against the side of the index finger and resist abduction
  • 57. TESTING THE GRIP •C7, C8, T1 •Ask the patient to squeeze two of your fingers as hard as possible and not let them go. You should normally have difficulty removing your fingers from the patient's grip. Test both grips simultaneously with arms extended or in the lap.
  • 58. LUMBRICALS •Lateral median and medial ulnar, C8, T1 •Phalanges extension •Stabilize the patient's metacarpophalangeal joint in hyperextension by pressing your finger against the palmar surface of the middle phalanx so that the long extensors cannot act, and resist extension of the distal phalanx
  • 59. HIP Iliopsoas •Spinal branches and femoral N.; L1, L2, L3 •Hip flexion •The patient flexes the thigh at the hip near 90°. Resist this by pressing on the anterior aspect of the thigh just proximal to the knee.
  • 60. GLUTEUS MAXIMUS •Inferior gluteal N.; L5, S1, S2 •Hip extension •The patient lies supine with legs extended. Slightly flex the hip by placing your hand under the knee. Ask the patient to extend the hip to support the weight of the pelvis off the couch.
  • 61. HIP ADDUCTORS •Oburator N.; L2, L3, L4 •Hip adduction •The patient lies supine with legs extended. Resist adduction of the hip by pressing against the medial surface of the knee, stabilizing with your other hand against the side of the pelvis.
  • 62. GLUTEUS MEDIUS AND TENSOR FASCIAE LATAE •Superior gluteal N.; L4, L5, S1 •Hip abduction •The patient lies supine with legs extended. Resist abduction of the hip by pressing against the lateral surface of the knee, stabilizing with your hand against the opposite side of the pelvis.
  • 63. KNEE- QUADRICEPS •Femoral N.; L2, L3, L4 •Knee extension •The patient lies supine with legs extended. Use one hand to lift the patient's leg from underneath the knee to about 20°knee flexion and ask the patient to extend the knee, resisting with your other hand over the patient's lower shin.
  • 64. HAMSTRINGS •Knee flexion •Sciatic N.; L5, S1, S2 •The patient lies supine with the knee flexed at 90°. Hold the leg at the ankle and resist pulling of the heel in towards the buttock.
  • 65. ANKLE AND FOOT Gastrocnemius •Tibial N.; S1, S2 •Ankle extension •The patient lies supine with legs extended and plantar-flexing the foot. Hold the foot at the metatarsal heads and resist plantar-flexion.
  • 66. TIBIALIS ANTERIOR •Deep peroneal N.; L4, L5 •Ankle dorsiflexion •The patient lies supine with legs extended and the foot dorsi-flexed. Hold the foot over the dorsal surface and resist dorsi-flexion.
  • 67. TIBIALIS POSTERIOR •Tibial N.; L4, L5 •Ankle inversion •Hold the patient's foot medially at the first metatarsal and resist inversion.
  • 68. PERONEI (LONGUS AND BREVIS) •Superficial peroneal N.; L5, S1 •Ankle eversion •Hold the patient's foot laterally at the fifth metatarsal and resist eversion
  • 69. EXTENSOR HALLUCIS LONGUS •Deep peroneal N.; L5, S1 •Great toe extension •The patient dorsiflexes the distal phalanx of the great toe. Press against the dorsal surface of the distal phalanx to resist dorsiflexion.
  • 70. EXTENSOR DIGITORUM BREVIS •Deep peroneal N.; L5, S1 •Toe extension •The patient dorsiflexes the proximal phalanges of the toes and attempts to 'spread' the toes. Alternatively, press against the dorsal surfaces of the middle phalanges. Observe and palpate the muscle belly 4 cm distal to the lateral malleolus.
  • 71. FLEXOR DIGITORUM LONGUS •Tibial N.; L5, S1, S2 •Toe flexion •Hold the patient's toes with your fingers over the plantar surfaces and resist flexion.
  • 72. GENERAL INSTRUCTIONS •Encourage the patient to relax, then position the limbs properly and symmetrically. •Hold the reflex hammer loosely between your thumb and index finger so that it swings freely in an arc within the limits set by your palm and other fingers. •With your wrist relaxed, strike the tendon briskly using a rapid wrist movement. Your strike should be quick and direct, not glancing. •Note the speed, force, and amplitude of the reflex response and grade the response using the scale below. Always compare the response of one side with the other.
  • 73. SCALE FOR GRADING REFLEXES
  • 74. REINFORCEMENT •A technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity. •Tell the patient to pull just before you strike the tendon.
  • 75. THE BICEPS REFLEX (C5, C6) •The patient's arm should be partially flexed at the elbow with palm down. •Place your thumb or finger firmly on the biceps tendon. •Strike with the reflex hammer so that the blow is aimed directly through your digit towards the tendon. •Observe flexion at the elbow, and watch for and feel the contraction of the biceps muscle.
  • 76. THE TRICEPS REFLEX (C6, C7) •The patient may be sitting or supine. Flex the patient's arm at the elbow, with palm toward the body, and pull it slightly across the chest. •Strike the triceps tendon above the elbow. Use a direct blow from directly behind it. •Watch for contraction of the triceps muscle and extension at the elbow.
  • 77. If you have difficulty getting the patient to relax, try supporting the upper arm as illustrated. Ask the patient to let the arm go limp, as if it were “hung up to dry.” Then strike the triceps tendon.
  • 78. THE SUPINATOR OR BRACHIORADIALIS REFLEX (C5, C6) •The patient's hand should rest on the abdomen or the lap, with the forearm partly pronated. •Strike the radius with the point or flat edge of the reflex hammer, about 1 to 2 inches above the wrist. •Watch for flexion and supination of the forearm.
  • 79. THE KNEE REFLEX (L2, L3, L4) •The patient may be either sitting or lying down as long as the knee is flexed. •Briskly tap the patellar tendon just below the patella. •Note contraction of the quadriceps with extension at the knee.
  • 80. THE ANKLE REFLEX (PRIMARILY S1) •If the patient is sitting, dorsiflex the foot at the ankle. Persuade the patient to relax. •Strike the Achilles tendon. •Watch and feel for plantar flexion at the ankle. Note also the speed of relaxation after muscular contraction.
  • 81. ANKLE CLONUS •Support the knee in a partly flexed position. With your other hand, dorsiflex and plantar flex the foot a few times while encouraging the patient to relax, and then sharply dorsiflex the foot and maintain it in dorsiflexion.Look and feel for rhythmic oscillations between dorsiflexion and plantar flexion. •In most normal people, the ankle does not react to this stimulus.
  • 82. SUPERFICIAL SPINAL REFLEXES
  • 83. ABDOMINAL REFLEXES •Lightly but briskly stroke each side of the abdomen, above (T8, T9, T10) and below (T10, T11, T12) the umbilicus. •Note the contraction of the abdominal muscles and deviation of the umbilicus toward the stimulus.
  • 84. THE PLANTAR REFLEX (L5, S1) •With an object such as a key or the wooden end of an applicator stick, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball. •Note movement of the big toe, normally plantar flexion. •Babinski response: Instead of the normal flexor response, dorsiflexion of the great toe precedes all other movement. This is followed by spreading and extension of the other toes, by
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