Motor Examinations & coordination

Motor Examinations

الموضوع مرتب بحيث يوضح في البداية ال normal لكل test على ال upper & lower extremities ومن ثم ال abnormal لكل منهما
لمن يرغب بتحميل جميع الفيديوهات سوف اقوم برفعها قريبا ان شاء الله وسوف ابلغكم عنها ايضا


normal

FIRST : upper extremities

Inspection and Palpation ( Muscle bulk or state )
The muscles are inspected for bulk and fasciculations and, when
indicated, palpated for tenderness, consistency and contractures[/size]


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Tone
Muscle tone is assessed by putting selected muscle groups through
passive range of motion. The most commonly used maneuvers for the upper
extremities are flexion and extension at the elbow and wrist



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Strength testing

Muscle strength is tested from the proximal to the distal part of the
extremity so that all segmental levels for the extremity are tested (for
the upper extremity that is C5 to T1 – see table). Muscle power is
graded on a scale of 0-5 (see table)



Strength Testing


C5 – Shoulder extension
C6 – Arm flexion
C7 – Arm extension
C8 – Wrist extensors
T1 – Hand grasp



Muscle Strength Grading


0 – No contraction
1 – Slight contraction, no movement
2 – Full range of motion without gravity
3 – Full range of motion with gravity
4 – Full range of motion , some resistance
5 – Full range of motion, full resistance





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Stretch or Deep Tendon Reflexes
A brisk tap to the muscle tendon using a reflex hammer produces a
stretch to the muscle that results in a reflex contraction of the
muscle. The muscles tested, segmental level, and grading of DTR's is
listed below.



Levels for DTR's


Biceps – C5-6
Brachioradialis – C5-6
Triceps – C7
Finger Flexors – C8


Grading DTR's

0 – Absent
1 – Decreased but present
2 – Normal
3 – Brisk and excessive
4 – With clonus






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Testing for pronator drift
The patient extends their arms in front of them with the palms up and
eyes closed. The examiner watches for any pronation and downward drift
of either arm. If there is pronator drift this indicates corticospinal
tract disease




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SECOND : Lower extremities

Inspection and Palpation
The muscles are inspected for bulk and fasciculations and, when
indicated, palpated for tenderness, consistency and contractures




[ندعوك للتسجيل في المنتدى أو التعريف بنفسك لمعاينة هذا الرابط]


Tone
Muscle tone is assessed by putting selected muscle groups through
passive range of motion. The most commonly used maneuvers for the lower
extremities are flexion and extension at the knee and ankle




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Strength testing
Muscle strength is tested from the proximal to the distal part of the
extremity so that all segmental levels for the extremity are tested (for
the lower extremity that is L2 to S1 – see table). Muscle power is
graded on a scale of 0-5 (see table)


Strength Testing


L2 – Hip flexion
L3 – Knee extension
L4 – Knee flexion
L5 – Ankle dorsiflexon
S1 – Ankle plantar flexion



Muscle Strength Grading


0 – No contraction
1 – Slight contraction, no movement
2 – Full range of motion without gravity
3 – Full range of motion with gravity
4 – Full range of motion, some resistance
5 – Full range of motion, full resistance





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Stretch or Deep Tendon Reflexes
A brisk tap to the muscle tendon using a reflex hammer produces a
stretch to the muscle that results in a reflex contraction of the
muscle. The muscles tested, segmental level, and grading of DTR's is
listed below.


Levels for DTR's


Patellar or Knee – L2-4
Ankle – S1-2



Grading DTR'snge]0 – Absent
1 – Decreased but present
2 – Normal
3 – Brisk and excessive
4 – With clonus





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Plantar Reflex
The plantar reflex is a superficial reflex obtained by stroking the skin
on the lateral edge of the sole of the foot, starting at the heel
advancing to the ball of the foot then continuing medially to the base
of the great toe. The normal response is flexion of all the toes. The
abnormal response is called a Babinski sign and consists of extension of
the great toe and fanning of the rest of the toes




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Abnormal

FIRST : upper extremities

Inspection & Palpation
In this patient there are fasciculations (spontaneous
contraction of a motor unit) noted in the deltoid muscle as well
as atrophy. There is also atrophy of the interosseous muscles of
the hands. These findings can be seen in motor neuron disease
such as amyotrophic lateral sclerosis




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Tone
There is increased tone in the right upper extremity that is rate
dependent with the clasp-knife phenomena noted when the arm is flexed.
This is spasticity from an upper motor neuron lesion






Strength testing
With an UMN lesion the fine, fractionated movements of the fingers and
hand are lost. Distal extremity weakness is greater than proximal
weakness. With greater effort to move the paretic hand, there is
overflow activation of proximal muscles and even of the contralateral
hand, which produces mirror or synkinetic movements




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Stretch or Deep Tendon Reflexes
It is always important to compare right vs. left. The first patient
shown has hyperreflexia or 3+ DTR's of the right biceps, triceps and
brachioradialis. The second patient has hyperreflexia of the right
finger flexors. Hyperreflexia is one of the signs of a UMN lesion




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Testing for pronator drift
With an UMN lesion there is pronation and downward drift of the
outstretched supinated arm. This is because the pronators overpower the
weaker supinators. Another name for this sign is a pronator Babinski




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SECOND : Lower extremities

Inspection & Palpation
There is hypertrophy of this patient's left leg. Closer inspection
of that extremity shows hyperpigmented skin lesions suggesting
segmental neurofibromatosis. A thorough skin search can provide
important clues to diagnosis especially in the neurocutaneous
syndromes




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Tone
There is spasticity on passive range of motion of the patient's right
ankle with decrease range of motion and clonus which is caused by
repetitive contraction of the stretched gastrocnemius muscle. Range of
motion at the knee would also demonstrate spasticity. These findings are
part of the UMN syndrome




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Testing of the muscle strength in this patient shows 1/5 weakness of
dorsiflexion, plantar flexion, inversion and eversion of the right ankle
with normal proximal strength




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Stretch or Deep Tendon Reflexes
There is hyperreflexia of the right knee jerk (3+) with a rightsided
crossed adductor response (the crossed adductor contraction occurred
because of the increased right leg tone which resulted in reflex
contraction of the adductor magnus with the very slight stretch of this
muscle caused by tapping the opposite knee). There is also hyperreflexia
with clonus (4+ DTR) of the right ankle. The second patient
demonstrates a 4+ ankle jerk on the left with sustained clonus.
Hyperreflexia is one of the signs of the UMN syndrome


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Plantar Reflex
The patient has a Babinski sign on the right with an up going great toe
and dorsiflexion and fanning of the other toes. This is an important
indication of UMN disease




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]normal


Hand Rapid Alternating Movements
Finger tapping, wrist rotation and front-to-back hand
patting. Watch for the rapidity and rhythmical performance of the
movements noting any right-left disparity





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Finger-to-nose
The patient moves her pointer finger from her nose to the
examiner's finger as the examiner moves his finger to new positions and
tests accuracy at the furtherest outreach of the arm






Heel-to-shin
The patient places her heel on the opposite knee then runs
the heel down the shin to the ankle and back to the knee in a smooth
coordinated fashion





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Abnormal

Tremor[
A cerebellar intention tremor (1st scene in this movie)
arises mainly from limb girdle muscles and is maximal at the
most demanding phase of the active movement. This must be
distinguished from a postural tremor (fine distal 8-13 Hz)(2nd
scene) or resting tremor (coarse distal 5-6 Hz pill-rolling
type of tremor)(3rd scene)





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Hand Rapid Alternating Movements
Movements are slow and irregular with imprecise timing. Inability
to perform repetitive movements in a rapid rhythmic fashion is
called dysdiadochokinesia

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Finger-to-nose
Under (hypometria) and over (hypermetria) shooting of a target (dysmetria) and the decomposition of movement
(the breakdown of the movement into its parts with impaired
timing and integration of muscle activity) are seen with
appendicular ataxia


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Heel-to-shin
The patient with ataxia of the lower extremity will have
difficulty placing the heel on the knee with a side-to-side
irregular over- and undershooting as the heel is advanced down
the shin. Dysmetria on heel-to-shin can be seen in midline ataxia
syndromes as well as cerebellar hemisphere disease so there is
overlap between the two types of ataxias for this finding


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