Examination of tone, power and

reflexes
 Combined examinations
• Remember the order of your examination:
• Gait
• Cranial nerves
➢Tone
➢Power
➢Reflexes
• Coordination
• Sensory
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 Note
• This study guide is designed with
right-handed examiners in mind.
– please substitute appropriately if left-
handed
• Arrows on photographs depict the
direction of movement of the limb

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 Tone & Power - Spinal Nerves

• We are going to examine muscle tone and

power of muscles which are innervated by
particular spinal nerves.

• The nerves are numbered in relation to the

spinal column:

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 Spinal Nerves
• 8 Cervical nerves
– C1 nerve is above C1 bone – as there are 8
nerves and only 7 vertebrae.
– C8 nerve is below C7 (above T1) vertebra.
– T1 Nerve is below T1 vertebra - and so on….
• 12 Thoracic
• 5 Lumbar
• 5 Sacral

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 Spinal cord section
• Posterior column
ipsilateral (crosses at
medulla)
– proprioception
– vibration
• Spinothalamic tract
contralateral (crosses at
spinal level)
– pain • Motor supply
– light touch  Anterior corticospinal
– temperature  Lateral corticospinal

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 The motor system
Messages travel from the motor cortex via subcortical
nuclei and brainstem to spinal cord, thence to
nerve roots, peripheral nerves and finally to
muscles
• Upper Motor Neurone (UMN)
– From the motor cortex to anterior horn cell of the
spinal cord
• Lower Motor Neurone (LMN)
– from anterior horn cell to neuromuscular junction

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 Contents

1. Overview of tone, power & reflexes

2. Upper limb
• Tone
• Power
• Reflexes
3. Lower limb
• Tone
• Power
• Reflexes

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Testing muscle tone

An overview
 Tone
• NORMAL
– passive movement of the limbs should be neither
floppy nor stiff
• INCREASED due to -
– lesions of pyramidal tract (UMN) – SPASTICITY
– or lesions of the extrapyramidal tract – RIGIDITY
• REDUCED
– caused by LMN lesions - FLACCIDITY
Abnormal tone will be accompanied by other signs
which help to localise the lesion

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 Rigidity and Spasticity
• Rigidity - constant, sustained resistance
throughout movement. Best demonstrated
when limb moved slowly. (Extra–pyramidal
tract lesion)
• Spasticity - detected on rapid movements
of a passive limb. This is a feature of
upper motor lesions (pyramidal tract).

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Testing muscle power

An overview
The grading of muscle power (MRC)
Grade Meaning
0 Complete paralysis
1 Flicker of contraction possible
2 Movement possible if gravity eliminated

3 Movement against gravity but not resistance

4 Movement possible against some resistance

5 Power normal (it is not normally possible to

overcome a normal adult’s power)
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 Patterns of weakness
• Help to localise the problem within the
nervous system
• A limited examination allows you to
differentiate between UMN and LMN lesions
• Different patterns of LMN weakness may
require more detailed examination

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 Patterns of weakness
• UMN lesion
– there is weakness of the:
• extensors in the arms
• flexors in the legs
– The unopposed action of unaffected muscles produces the
characteristic posture seen in patients with stroke

• LMN lesion
– involvement of nerve endings (peripheral
neuropathy) produces a predominantly distal
pattern of weakness

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Testing the reflexes

An overview
 Reflexes
Normal reflex arc requires :-
⚫ Stimulus to stretch receptors

⚫ Intact sensory afferent pathway

⚫ Link with a motor unit

⚫ Intact motor neurone

⚫ Contractile element

The order in which you test reflexes should be logical,

though may vary from one examiner to another
The patient must be relaxed

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 Documenting reflexes
Reflexes can be recorded as follows:

Absent -
Present with reinforcement +/-
Normal + or ++
Brisk +++

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 Patterns of reflex change
UMN lesion
• Reflexes brisk below the level of the lesion
• Plantar response is usually extensor

LMN lesion (peripheral neuropathy)

• reflexes are absent
– distal reflexes are first to be lost

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 Summary
Parameter UMN lesion LMN lesion (peripheral
neuropathy)*
Posture Flexed UL, Extended LL May be wasting,
fasciculation
Tone Increased (spasticity) Reduced (flaccidity)
Power Weakness of UL extensors Distal weakness
and LL flexors
Reflexes Brisk Absent
Plantar response Extensor Flexor or absent

There are other patterns of lower motor neurone

* lesions (nerve root, individual peripheral nerve).

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 Reminder
• What you have learned so far will allow
you to distinguish between UMN and LMN
lesions
• In future you will learn additional skills
needed to localise lesions according to
particular presentations
– E.g. examination of the intrinsic hand muscles
in someone with weakness or tingling in the
hand/fingers.
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Examining the upper limbs
 Inspection
Firstly inspect the upper limbs for:
• Wasting
• Fasciculation
• Asymmetry
• Abnormal resting posture
• Involuntary movements
• Tremor

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 Preliminary upper limb
examination 1
To get a quick idea of possible issues - ask
the patient to:-
• With both arms outstretched and
supinated (palms up) and eyes closed -
look for ‘pronator drift’
– an early sign of upper motor neurone lesion,
where there is pronation of the palm and
downward movement of the arm)

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 Testing Pronator drift

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 Preliminary upper limb exam 2

• “Play the piano” with

arms outstretched
– asymmetrical loss may
be an early sign of
cortical or
extrapyramidal
disease

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 Preliminary upper limb exam 3
• Repetitive opening
and closing of
thumb and index
finger
– attenuation of
amplitude and speed
is a common sign in
Parkinson's disease.

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Testing muscle tone
Upper limbs
 Wrist tone
• Passively rotate the
wrist whilst
supporting the arm.
Check for rigidity
suggestive of
pyramidal problem.
• Repeat on other
side.

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 Testing tone in the arms
• Support the elbow with
your left hand
• Hold patient’s hand as if
shaking hands
• Rapidly supinate and
pronate the arm
• Use the same technique
on each arm
• Always use the same
hand to assess
movement for the
patient’s right and left

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 Testing tone in the arms
• While still supporting
the elbow passively
flex and extend the
elbow
• Use same technique
on both arms
• If tone is normal there
will be no resistance
to these movements

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 Pyramidal tract (UMN) lesion
SPASTICITY
• There is initial resistance to movement which
gives way as the movement continues
• In the arm this is seen as
– SUPINATOR CATCH

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Testing muscle power
Upper limbs
 Power
• Ask the patient to make the required
movement
• Attempt to overcome the movement
– remembering that this is not a test of relative
strength
• Avoid mechanical advantage to the examiner
• Always compare sides

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 Summary of motor supply to the upper limb

Abduction
C5/6 Adduction
C6/7/8
Flexion
Extension C5/6
C7/8
Flexion
Extension C6/7
C7/8
Flexion
Adduction Extension C7/8
T1: Ulna C7/8

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 Shoulder abduction (C5/6) and adduction
(C6/7/8)
Position patient with shoulders
abducted to 90°
• Ask patient to maintain
position whilst you attempt
to overcome by pressing
down on upper arm – close- “Stop me
to the elbow pushing your
arm down”

Position patient with arms at

approx. 30° of abduction,
with elbows flexed
• Ask patient to bring elbows
towards side against “Stop me
resistance pushing your
arm up”

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 Elbow flexion
(C5/6) and extension (C7/8)
Position patient with elbow flexed
• Ask them to resist your
attempt to straighten their arm

“Pull me towards you”

Position patient with elbow

extended beyond 90 °
• Ask them to resist your
attempt to flex the elbow
(‘push me away’)
“Push me away”
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 Wrist extension (C7/8)
Position patient with
wrist in neutral.
• While supporting
above their wrist
ask them to resist
your attempt to
move their hand
down
“Stop me pushing your hand down”

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 Finger extension (C7/8)
Position patient with
fingers extended
• While supporting
their palm ask
them to resist your
attempt to flex
fingers
“Stop me trying to bend
your fingers down”

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 Finger flexion (C7/8)
• Ask patient to curl fingers
towards palm
• And to keep fingers flexed
while you attempt to
“Stop me pulling your straighten them
fingers straight”

Alternatively,
• ask them to squeeze two of
your fingers placed in the
patient’s palm
“Squeeze my fingers”
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 Finger abduction (T1: ulnar)
Support patient’s wrist with
your left hand
• Ask patient to spread fingers
wide
“Stop me pushing • Ask patient to maintain this
your fingers” position while you try to
push index finger inwards
• Ask patient to maintain this
position while you try to
push little finger inwards
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 Thumb abduction (T1: median)
Support patient’s wrist
with your left hand
• Position the patient
with their thumb at 90°
to their palm
• Ask them to maintain
that position against
resistance
“Stop me pushing your thumb
into to your palm”
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 Thumb adduction (T1, Ulnar)
Support patient’s wrist
with your left hand
• Ask patient to trap
your index and middle
fingers between the
base of their thumb
and their index finger
• Ask them to maintain “Stop me lifting your thumb
that position while you up”
try to lift their thumb

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 Thumb opposition (T1,Median)
Support patient’s wrist
with left hand
• Ask patient to place
tip of thumb onto tip
of index finger
• And to hold this
position while you try “Stop me breaking the loop”
to separate the thumb
and index finger

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Testing the reflexes
Upper limbs
 The reflexes

Biceps (C5/6)
Triceps (C7/8)
Supinator
(C6)

Finger (C8)

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 Testing for reflexes
• Position the limb correctly
• Hold the tendon hammer like a hammer, allow the
weight of the hammer to do the work for you.
• Place your finger over the tendon and strike it,
– for some reflexes you will strike the tendon itself (e.g.
triceps)
• Observe the relevant muscle for contraction
– (not the limb movement)
• Be aware of the range of normality.
– Abnormal reflexes rarely seen without other relevant signs

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 Reinforcement
Where a reflex appears difficult
to elicit, reinforcement might
be tried.
• For upper limb –
– Ask the patient to close their
eyes and grit their teeth
– Immediately strike the tendon

Reinforcement for a upper limb

reflex – with patient’s eyes
closed “grit your teeth”

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 Supinator (brachioradialis) reflex (C6)
• Position patient sitting
relaxed, with elbows
flexed and hands
resting on thigh/pillow
• Place your left
index/middle finger(s)
over supinator tendon
• Strike finger(s) with
falling head of hammer
⚫ Observe for contraction of
brachioradialis here
• Observe slight elbow
⚫ You may notice momentary
flexion or contraction of
elbow flexion belly of brachioradialis

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 Biceps reflex (C5/6)
• In same position clasp
patient’s elbow so that
biceps tendon can be felt
under your thumb or finger
• Strike your thumb or finger
• Observe elbow flexion
– there may be little movement,
but you should feel the
contraction

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 Triceps reflex (C7/8)
Position patient with their
arm across the abdomen
with elbow flexed to 90°
• Strike the triceps tendon
direct
• Observe
– for contraction of the
muscle belly
(You may see some elbow
extension)
You may feel the muscle
contract with your free
hand
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 The finger jerk (C8)
Ask patient to rest their
fingers on the fingers of
your left hand and curl their
fingers slightly
• Strike your fingers
– Patient’s fingers may flex
– Usually only present when
there is a pathological
exaggeration of the reflexes

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 Summary
• Complete the full examination on the
upper limbs (inspection; tone; power and
reflexes) before proceeding to the lower
limbs.

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Examining the lower limbs
Summary of lower limb motor supply

Abduction Adduction
L4/5/S1 L2/3/4 Flexion
Extension L2/3
L5/S1/2
Flexion
Extension
L5/S1
L3/4

Dorsiflexion
Eversion Inversion L4
L5/S1 L5/S1 Plantar flexion
S1/S2

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Testing muscle tone
Lower limbs
 Testing tone in the legs
• With the patient relaxed, place your hands on the
thigh and roll the whole leg
• Observe the movement of the foot
• If tone is normal the range of movement of the foot
is similar to the rotation of the leg
Alternatively
• Flex and extend the knee
• If tone is normal there should be no resistance to
this movement

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 Lower Limb Tone

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 Testing tone in the legs (Clonus)
Position the patient with the
knee flexed and the hip
externally rotated
• Sharply dorsiflex the foot
In most people with normal
tone the foot will not move
Sustained clonus is a • But 2-3 beats of clonus
sign of an upper motor (plantar flexion followed by
neurone problem and dorsiflexion of the foot)
is seen as sustained
can be within normal limits
“tapping” of the foot
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 Pyramidal tract (UMN) lesion
SPASTICITY
• There is initial resistance to movement which
gives way as the movement continues
• In the leg this is seen as
– CLASP KNIFE phenomenon
– There is also usually SUSTAINED CLONUS
(>3-4 beats)

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Testing muscle power
Lower limbs
Hip flexion (L2/3) and extension (L5/S1/2)
Testing flexion:
• Position the patient with the
leg elevated to approximately
30° “Stop me
• Press down on thigh whilst pushing your
patient maintains elevation leg down”

Testing extension:
• Position patient with leg flat
on couch
• Place your hand underneath
thigh and attempt to elevate “Stop me
leg whilst the patient trying to raise
presses down your leg up”
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 Knee flexion (L5/S1)

“Stop me trying to straighten your leg”

Position the patient lying with knee flexed

1. Place your left hand on patient’s knee
2. Place your right hand behind ankle
3. Ask the patient to bring their heel towards their
buttocks against resistance
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 Knee extension (L3/4)
Position patient lying with
knee flexed
• Place your left hand
under the patient’s
knee
• Place your right hand
over patient’s lower
shin or ankle
“Stop me trying to bend
your knee” • Ask patient to
straighten leg against
resistance
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 Dorsiflexion (L4) and plantar flexion (S1/2) of the
foot

• Dorsiflexion: Ask patient • Plantar flexion: Ask

to bring foot upwards patient to push foot down
• Attempt to overcome by • Attempt to overcome by
pressing down on foot pressing upwards on sole

“Stop me pushing your foot

“Stop me pushing your foot
down”
up”
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Testing the reflexes
Lower limbs
 The reflexes

Knee (L3/4)

Ankle (S1/2)
Plantar (L5/S1/2)
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 Testing for reflexes
• Position the limb correctly
• Hold the tendon hammer like a hammer
• Place your finger over the tendon and strike it,
– for some reflexes you will strike the tendon itself (e.g.
patellar reflex)
• Observe the relevant muscle for contraction
– (not the limb movement)
• Be aware of the range of normality.
– Abnormal reflexes are rarely seen without other
relevant signs

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 Reinforcement
Where a reflex appears
difficult to elicit,
reinforcement might be tried.
For Lower limbs:
• Ask the patient to grasp the
fingers of each hand and to
pull apart on instruction with
their eyes closed.
• Immediately strike the
tendon
Reinforcement for a lower limb
reflex (with patient’s eyes closed)

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 Knee reflex (L3/4)
Support one or both
knees, so they are
slightly bent
• Strike the patellar
tendon direct
• Observe
– quadriceps contraction
– with or without knee
extension
Infrapatellar ligament

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 Ankle reflex S1/2
Place your left hand on
ball of patient's foot
Passively dorsiflex the
ankle
• Strike your fingers
• Observe/feel for plantar
flexion
• Alternatively, strike the
Achilles tendon direct.

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 Plantar reflex (L5/S1/2)
Patient seated with leg flat
on couch
• Drag a blunt object (e.g.
tongue depressor) along
the lateral border of the
foot and across the sole
towards other side
• The normal response is
plantar-flexion of the big
An abnormal response (+ve Babinski sign) is
toe
the big toe dorsiflexes (activation of extensor – may be absent if feet are
hallucis longis) and the other toes may splay cold
and is due to an UMN lesion

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 Completion

Following examination of tone, power &

reflexes, you will proceed to examination of:
➢Coordination

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