1. By:
Vibhushit Kaul
69/09

2. Outline
•Anatomy
•Inspection and Palpation
•Posture and abnormal movements
•Tone and Power
•Reflexes
•Coordination
•Stance and gait

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.

8. Inspection and Palpation
Look for:
•any asymmetry, inspecting both proximally
and distally.
•any deformities such as clawing of the
hands or pes cavus.
•wasting or hypertrophy, fasciculation and
involuntary movements.
•Palpate muscles to assess their bulk.

10. Causes of Muscle wasting
•Lower motor neurone lesions, peripheral
nerve section
•Longstanding or developmental upper
motor neurone damage disuse atrophy of
muscle groups
•Muscle disorders
•Rheumatoid arthritis
•Cachexia

11. Posture and Abnormal Movements
Ask the patient to hold the arms outstretched with the eyes
closed:
• Pyramidal drift describes a tendency for the hand to move
upward and supinate if the hands are held outstretched in a
pronated position (palms downward), or to pronate
downward if the hands are held in supination.
• Cerebellar drift is generally upward, with excessive
rebound movements if the hand is suddenly displaced
downward by the examiner.
• Parietal drift is an outward movement on displacing the
ulnar border of the supinated hand.

12. Abnormal movements
•Fasciculations
•Tremors: Rest tremors, Postural tremors,
Action tremors, Hysterical tremors, Rubral
tremors
•Myoclonic jerks
•Athetosis
•Chorea
•Ballism or Hemiballismus

13. •Pseudoathetosis
•Dystonia
•Tics
•Tetany
•Cramps

14. TONE
•Muscular tone refers to the state of muscle
tension or contraction
•For clinical purposes, it is the resistance felt
by the examiner when moving a joint
passively through its range of movement.

15. Examination sequence
•Ask the patient to lie supine on the examination couch, relax and 'go
floppy'.
•Passive movements of the joints should be through as full a range as
possible and both slowly and quickly.
•In the upper limb hold the patient's hand as if shaking hands, using your
other hand to support the patient's elbow. Then rotate the forearm, flex and
extend the wrist, elbow and shoulder, varying the speed and direction.
•With the lower limb begin by rolling or rotating the leg from side to side,
then briskly lift the knee into a flexed position.
•Knee clonus: with the patient relaxed and the knee extended, sharply
push with your thumb and forefinger above the patella towards the foot,
sustaining the pressure for a few seconds.
•Ankle clonus: support the patient's leg with both the knee and ankle
resting in 90° flexion. Briskly dorsiflex and partially evert the foot and
sustain the pressure

16. Common abnormalities
•Hypotonia: decreased muscle tone
•Hypertonia: increased muscle tone.
There are two principal types of hypertonia:
 spasticity
 rigidity

17. Power
•Muscle power is tested for groups of muscles
moving various joints.
•Strength of individual muscle groups is tested
by comparing them with examiner‟s own
strength
•Before testing power always look for
tenderness and contracture of muscles and
joints
•Fix the proximal joints to avoid movements by
uninvolved muscles.

18. 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

19. Examination sequence
•Test the power of individual muscle groups
in both limbs alternately to compare.
•Ask the patient to contract a group of
muscles to maintain a position and resist
your attempt to displace the limb (isometric
testing).
•Ask the patient to put the joint through a
movement while you try to oppose the action
(isotonic testing).

20. Muscles of Shoulder Girdle & Scapula
Supraspinatus:
•Main Segmental Supply –
C5, C6
•Nerve supply-Suprascapular
Nerve
•Action: Shoulder abduction
•Test: The patient rests the
arm down by the side. Grip
at the elbow and resist
abduction

21. 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

22. Deltoid

23. 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

24. 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

25. 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.

26. 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 palm of the patient's
hand to resist movement of
the hand posteriorly.

27. 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

28. 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

29. 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

30. 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

31. 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.

32. Forearm: Supinator
•Radial N.; C6, C7
•Forearm supination
•Grasp the patient in a
handshake with the
patient's elbow extended
and resist supination.

33. Pronator teres
•Median N.; C6, C7
•Forearm pronation
•Grasp patient in a
handshake with his
elbow extended and resist
pronation.

34. 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

35. 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.

36. 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

37. 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.

38. 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

39. 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.

40. 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

41. 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.

42. 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.

43. 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.

44. 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

45. 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.

46. 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

47. 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.

48. 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.

49. 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.

50. 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.

51. 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.

52. 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.

53. 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.

54. 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.

55. Tibialis posterior
•Tibial N.; L4, L5
•Ankle inversion
•Hold the patient's foot
medially at the first
metatarsal and resist
inversion.

56. Peronei (longus and brevis)
•Superficial peroneal N.;
L5, S1
•Ankle eversion
•Hold the patient's foot
laterally at the fifth
metatarsal and resist
eversion

57. 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.

58. 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.

59. 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.

61. 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.

62. Scale For Grading Reflexes

63. 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.

65. 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.

67. 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.

68. 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.

69. 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.

70. 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.

72. 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.

74. 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.

75. Superficial spinal reflexes

76. 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.

77. 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 marked dorsiflexion of the ankle, and by
flexion withdrawal of the hip and knee. It is pathognomonic
of an UMN lesion.

79. Coordination
To assess coordination, observe the
patient's performance in:
•Rapid alternating movements
•Point-to-point movements
•Gait and other related body movements
•Standing in specified ways

80. Rapid Alternating Movements
•Ask the patient to tap your palm with the
tips of the fingers of one hand, alternately in
pronation and supination, as fast as
possible.
•In cerebellar disease, one movement
cannot be followed quickly by its opposite
and movements are slow, irregular, and
clumsy. This abnormality is called
dysdiadochokinesis.

81. Point-to-Point Movements
Finger-to-nose Test
•Ask the patient to touch the point of the nose and then the
tip of your finger, held at arm's length in front of the
patient's face, using their index finger.
•Ask the patient to repeat the test with the eyes closed.

82. Heel-shin test
Ask the patient to place one heel on the opposite knee, and
then run it down the shin to the big toe. Note the smoothness
and accuracy of the movements. Repetition with the patient's
eyes closed tests for position sense. Repeat on the other
side.

83. Gait
Ask the patient to:
•Walk across the room or down the hall, then turn, and
come back. Observe posture, balance, swinging of the
arms, and movements of the legs.
•Walk heel-to-toe in a straight line (tandem walking).
•Walk on the toes, then on the heels
•Hop in place on each foot in turn
•Do a shallow knee bend, first on one leg, then on the
other.
•Rising from a sitting position without arm support and
stepping up on a sturdy stool.

84. Tandem walking Hopping

85. Stance
The Romberg Test:
This is mainly a test of position sense. The
patient should first stand with feet together
and eyes open and then close both eyes for
30 to 60 seconds without support. Note the
patient's ability to maintain an upright
posture. Normally only minimal swaying
occurs.

86. Test For Pronator Drift
•The patient should stand for 20 to 30 seconds with both arms straight
forward, palms up, and with eyes closed. A person who cannot stand
may be tested for a pronator drift in the sitting position.
•Now, instructing the patient to keep the arms up and eyes shut, tap the
arms briskly downward. The arms normally return smoothly to the
horizontal position.

87. 26/4/2013
Vibhushit Kaul