Appendix

General inspection

 Scars: may provide clues regarding previous spinal, axillary or upper

limb surgery.
 Wasting of muscles: suggestive of lower motor neuron lesions or disuse
atrophy.
 Tremor: there are several subtypes including resting tremor and intention
tremor.
 Fasciculations: small, local, involuntary muscle contraction and
relaxation which may be visible under the skin. Associated with lower
motor neuron pathology (e.g., amyotrophic lateral sclerosis).
 Pseudoathetosis: abnormal writhing movements (typically affecting the
fingers) caused by a failure of proprioception.
 Chorea: brief, semi-directed, irregular movements that are not repetitive
or rhythmic but appear to flow from one muscle to the next. Patients with
Huntington’s disease typically present with chorea.
 Myoclonus: brief, involuntary, irregular twitching of a muscle or group
of muscles. All individuals experience benign myoclonus on occasion
(e.g., whilst falling asleep) however persistent widespread myoclonus is
associated with several specific forms of epilepsy (e.g., juvenile
myoclonic epilepsy).
 Tardive dyskinesia: involuntary, repetitive body movements which can
include protrusion of the tongue, lip-smacking and grimacing. This
condition can develop secondary to treatment with neuroleptic
medications including antipsychotics and antiemetics.
 Hypomimia: a reduced degree of facial expression associated with
Parkinson’s disease.
 Ptosis and frontal balding: typically associated with myotonic
dystrophy.
Ophthalmoplegia

Weakness or paralysis of one or more

extraocular muscles responsible for eye
movements. Ophthalmoplegia can be
caused by a wide range of neurological
disorders including multiple sclerosis and
myasthenia gravis.

Pronator Drift Interpretation

o If the forearm pronates, with or

without downward movement,
the patient is considered to have
pronator drift on that side.
o The presence of pronator drift
indicates a contralateral
pyramidal tract lesion. Pronation
occurs because, in the context
of an UMN lesion, the supinator
muscles of the forearm are
typically weaker than the
pronator muscles.

Tone Abnormalities

o Hypertonia is increased tone (increased tightness of muscle tone).

o Hypotonia is decreased tone (decreased basic tension and
stiffness of muscle).
o Spasticity is associated with pyramidal tract lesions (e.g., stroke)
and rigidity is associated with extrapyramidal tract lesions (e.g.,
Parkinson’s disease). Spasticity and rigidity both involve increased
tone, so it’s important to understand how to differentiate them
clinically.
 o Spasticity is “velocity- dependent” meaning the faster you move
the limb, the worse it is. There is typically increased tone in the
initial part of the movement which then suddenly reduces past a
certain point (known as “clasp knife spasticity”). Spasticity is also
typically accompanied by weakness.

o Rigidity is “velocity-independent” meaning it feels the same if

you move the limb rapidly or slowly. There are two main subtypes
of rigidity:
 Cogwheel rigidity involves a tremor superimposed on the
hypertonia, resulting in intermittent increases in tone
during movement of the limb. (e.g., Parkinson disease)
 Lead pipe rigidity involves uniformly increased tone
throughout the movement of the muscle, associated with
neuroleptic malignant syndrome.

Power (Muscle Power Assessment Scale)

The MRC scale of muscle strength uses a score of 0 to 5 to grade the power
of a particular muscle group in relation to the movement of a single joint.

Score Description
0 No contraction
1 Flicker or trace of contraction
2 Active movement, with gravity
eliminated
3 Active movement against gravity
4 Active movement against gravity and
resistance
5 Normal power
Patterns of muscle weakness

o Upper motor neuron lesions: cause a pyramidal pattern weakness

that disproportionally affects upper limb flexors (upper limb
extensors are weaker than flexors in an upper limb neurological
assessment).
o Lower motor neuron lesions: Cause a focal pattern of weakness,
with only the muscles directly innervated by the damaged neurons
affected.

Reflexes

o Hyperreflexia: Exaggerated response of deep tendon reflexes

(overresponsive), associated with upper motor neuron lesion e.g.,
stroke and spinal cord injury.
o Hyporeflexia: Decreased response of deep tendon reflexes, below
normal or absent reflexes (areflexia) associated with lower motor
neuron lesion e.g., brachial plexus pathology.
o Record response as increased (+++), normal (++), decreased (+),
present only with reinforcement (+/-), absent (0).

o Though there is no universally defined system for grading reflexes,

they can be described as absent, hyporeflexic (present with
reinforcement), normal or brisk
o These are often written as: –, +, ++ or +++ respectively

Reference:

Macleod’s Clinical Examination 14th Edition, geekymedics.com