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Motor Testing
Motor Testing
Motor Testing
The UMNs are part of the Central Nervous System (CNS), which is
composed of neurons whose cell bodies are located in the brain or spinal
cord.
The LMNs are part of the Peripheral Nervous System (PNS), made
up of motor and sensory neurons with cell bodies located outside of the
brain and spinal cord. The axons of the PNS travel to and from the
periphery, connecting the organs of action (e.g. muscles, sensory
receptors) with the CNS.
Nerves which carry impulses away from the CNS are referred to
Efferents (i.e. motor) while those that bring signals back are called
Afferents (i.e. sensory).
Axons that exit and enter the spine at any given level generally
connect to the same distal anatomic area. These bundles of axons,
referred to as spinal nerve roots, contain both afferent and efferent
nerves. The roots exit/enter the spinal cord through neuroforamina in the
spine, paired openings that allow for their passage out of the bony
protection provided by the vertebral column.
UNM Lesion
LMN Lesion
Weakness
Yes
Yes
Atrophy
No *
Yes
Fasciculation
No
Yes
Reflexes
Increased
Decreased
Tone
Increased
Decreased
Motor Testing
The muscle is the unit of action that causes movement.
Normal motor function depends on intact upper and
lower motor neurons, sensory pathways and input from a
number of other neurological systems. Disorders of
movement can be caused by problems at any point
within this interconnected system.
Muscle Bulk and Appearance:
This assessment is somewhat subjective and quite
dependent on the age, sex and the activity/fitness level
of the individual. A frail elderly person, for example, will
have less muscle bulk then a 25 year old body builder.
With experience, you will get a sense of the normal
range for given age groups, factoring in their particular
activity levels and overall states of health.
Motor Testing
Things to look for:
Using your eyes and hands, carefully examine the major
muscle groups of the upper and lower extremities. Palpation of the
muscles will give you a sense of underlying mass. The largest and
most powerful groups are those of the quadriceps and hamstrings
of the upper leg (i.e. front and back of the thighs). The patient
should be in a gown so that the areas of interest are exposed.
Muscle groups should appear symmetrically developed when
compared with their counterparts on the other side of the body.
They should also be appropriately developed, after making
allowances for the patients age, sex, and activity level.
Muscle Assymetry
While both legs have well developed musculature,
the left has greater bulk.
Motor Testing
There should be no muscle movement when the limb is at rest.
Rare disorders (e.g. Amyotrophic Lateral Sclerosis) result in
death of the lower motor neuron and subsequent denervation of
the muscle. This causes twitching of the fibers known as
fasciculations, which can be seen on gross inspection of affected
muscles.
Tremors are a specific type of continuous, involuntary muscle
activity that results in limb movement. Parkinsons Disease (PD),
for example, can cause a very characteristic resting tremor of the
hand (the head and other body parts can also be affected) that
diminishes when the patient voluntarily moves the affected limb.
Benign Essential Tremor, on the other hand, persists throughout
movement and is not associated with any other neurological
findings, easily distinguishing it from PD.
Motor Testing
The major muscle groups to be palpated include:
biceps, triceps, deltoids, quadriceps and hamstrings.
Palpation should not elicit pain. Interestingly, myositis (a
rare condition characterized by idiopathic muscle
inflammation) causes the patient to experience weakness
but not pain.
Motor Testing
If there is asymmetry, note if it follows a particular pattern.
Remember that some allowance must be made for handedness
(i.e. right v left hand dominance).
Does the asymmetry follow a particular nerve distribution,
suggesting a peripheral motor neuron injury? For example,
muscles which lose their LMN innervation become very atrophic.
Is the bulk in the upper and lower extremities similar? Spinal
cord transection at the Thoracic level will cause upper extremity
muscle bulk to be normal or even increased due to increased
dependence on arms for activity, mobility, etc. However, the
muscles of the lower extremity will atrophy due to loss of
innervation and subsequent disuse.
Is there another process (suggested by history or other
aspects of the exam) that has resulted in limited movement of a
particular limb? For example, a broken leg that has recently
been liberated from a cast will appear markedly atrophic.
Description
0/5
No muscle movement
1/5
2/5
3/5
4/5
5/5
Normal strength
Wrist flexion (C 7, 8, T 1)
Have the patient try to flex their wrist as you provide resistance. Test
each hand separately.
The muscle groups which control flexion are innervated by the Median
and Ulnar Nerves.
Wrist extension (C 6, 7, 8)
Have the patient try to extend their wrist as you provide resistance.
The Extensor Radialis muscles control extension and are innervated by the Radial
Nerve. Damage to the radial nerve results in wrist drop (loss of ability to extend
the hand at the wrist). The nerve can be compressed against the humerus for a
prolonged period of time when an intoxicated person loses consciousness with
the inside aspect of the upper arm resting against a solid object (known as a
Saturday Night Palsy).
Elbow Flexion (C 5, 6)
Have the patient bend their elbow to ninety degrees while keeping their
palm directed upwards. Then direct them to flex their forearm while you
provide resistance.
The main flexor (and supinator) of the forearm is the Brachialis Muscle
(along with the Biceps Muscle). These muscles are innervated by the
Musculocutaneous Nerve
Elbow Extension (C 7, 8)
Have the patient extend their elbow against resistance while the arm is
held out (abducted at the shoulder) from the body at ninety degrees.
The main extensor of the forearm is the triceps muscle. The Triceps is
innervated by the Radial Nerve.
Shoulder Abduction (C 5, 6)
Have the patient flex at the elbow while the arms is held out from the
body at forty-five degress. Then provide resistance as they try to further
abduct at the shoulder.
The deltoid muscle, innervated by the axillary nerve, is the main muscle
of abduction.
Hip Flexion (L 2, 3, 4)
With the patient seated, place your hand on top of one thigh and
instruct the patient to lift the leg up from the table.
The main hip flexor is the Iliopsoas muscle, innervated by the femoral
nerve.
Sensory
Innervation
Motor Innervation
Contributing Spinal
Nerve Roots
Clinical
Radial Nerve
Back of thumb,
index, middle, and
ring finger; back of
forearm
C6, 7, 8
Ulnar Nerve
Abduction of fingers
(intrinsic muscles of
hand)
C7, 8 and T1
Median Nerve
Abduction of thumb
perpendicular to
palm (thenar
muscles).
C8, T1
Compression at carpal
tunnel causes carpal
tunnel syndrome
L1, 2
L4, 5; S1
Dorsiflexion of foot
(tibialis anterior
muscle)
Neurologic examination
GAIT & STATION
GAIT TESTING
TESTING OF STATION
(EQUILIBRATORY COORDINATION)
Cerebellar ataxia is not ameliorated by visual orientation
Have the patient stand in one place. This is a test of
balance, incorporating input from the visual, cerebellar,
proprioceptive, and vestibular systems. If they are able
to do this, have them close their eyes, removing visual
input. This is referred to as the Romberg test. Loss of
balance suggests impaired proprioception.
In disease of the cerebellum:
- lateral lobe, falling is toward the affected side
- frontal lobe, falling is to the opposite side
- midline or vermis, falling indiscriminately
Tandem Walking
Hemiplegic Gait
Parkinsonian Gait
Steppage Gait
Retropulsion
CEREBELLAR TESTING
The cerebellum fine tunes motor activity and assists with
balance. Dysfunction results in a loss of coordination and
problems with gait. The left cerebellar hemisphere
controls the left side of the body and vice versa.
Specifics of Testing: There are several ways of testing
cerebellar function. For the screening exam, using one
modality will suffice. If an abnormality is suspected or
identified, multiple tests should be done to determine
whether the finding is durable. That is, if the abnormality
on one test is truly due to cerebellar dysfunction, other
tests should identify the same problem. Gait testing, an
important part of the cerebellar exam.
CEREBELLAR TESTING
Finger to nose testing:
With the patient seated, position your index finger at a point in space in front of
the patient.
Instruct the patient to move their index finger between your finger and their
nose.
Reposition your finger after each touch.
Then test the other hand.
Ask the patient to touch the tips of each finger to the thumb of the same hand.
Test both hands.
CEREBELLAR TESTING
Rapid Alternating Hand Movements:
Direct the patient to touch first the palm and then the dorsal side of
one hand repeatedly against their thigh.
Then test the other hand.
Direct the patient to move the heel of one foot up and down along the
top of the other shin.
Then test the other foot.
THE END