1. Neurological Examination Motor System
Prof. Dr. Hülya Apaydın
Nöroloji AB Dalı

2. Cortically Originated Movement
I. Motor Tract (corticospinal tractus)
Extrapyramidal System (basal ganglia)
Cerebellum
Praxis Circuits
II. Motor Tract :
Alpha motor neurons of spinal cord
Neurons of the brainstem cranial nerve nuclei
Peripheral nerve
Neuromuscular junction
Muscle

3. Motor Function

5. Nervous System Examination

6. Terminology Used to Describe Muscle Weakness
Terminology Definition
-plegia (suffix) Paralysis of a muscle or a limb( 0/5)
-paresis (suffix) Weakness less severe than complete paralysis
(1/5 to 4/5)
Hemiparesis and hemiplegia Weakness of the arm and leg on one
side of the body
Quadriparesis and quadriplegia Weakness of both arm and both legs
Paraparesis and paraplegia Weakness of both legs

7. Grading Motor Strength Grade
0/5
No muscle movement
1/5
Visible muscle movement, but no movement at the joint
2/5
Movement at the joint, but not against gravity
3/5
Movement against gravity, but not against added resistance
4/5
Movement against resistance, but less than normal
5/5
Normal strength

8. Some Diagnostically Relevant Function of the Major Regions
Some major function of the region
Brain (hemispheric cortex )
Thought, language, memory, visual perception of contralateral space,
contralateral motor and sensory function
Brain (deep cerebral hemisphere )
Contralateral motor and sensory function
Brainstem
Eye movements, motor and sensory function of face and body,
alertness, sensation of nausea, coordination of extremities, balance
Cerebellum
Coordination of extremities, balance
Spinal cord
Motor and sensory function of the body and extremities,
bowl and bladder control
Nerve root
Motor and sensory function in territory of nerve root
Peripheral nerve
(or cranial nerve)
Motor and sensory function in territory of nerve or cranial nerve
Neuromuscular junction
Motor function of extremities, eye movements, swallowing, breathing
Muscle
Motor function

9. Characteristic Symtomps and Signs of Neurological Disease at Different Major Locations
Characteristic Symptoms and Signs Suggestive of Localization to This Region
Cognitive dysfunction, speech and language dysfunction, hemiparesis, hemisensory loss, visual field deficits, headache, upper motor neuron signs
Hemiparesis, hemisensory loss, headache, upper motor neuron signs
Diplopia, dysarthria, nausea, vomitting, vertigo
Alterations in level of consciousness
Ataxia of gait or extremities
Unilateral or bilateral weakness or sensory loss
Crossed hemiparesis (e.g.,weakness on one side of the face and the opposite side of the body)
Crossed hemisensory loss (e.g.,numbness on one side of the face and the opposite side of the body)
Upper motor neuron signs
Dysarthria, nausea, vomitting, vertigo Headache
General Location
Brain (hemispheric cortex)
Brain (deep hemisphere)
Brainstem
Cerebellum

10. Characteristic Symtomps and Signs of Neurological Disease at Different Major Locations (continue)
General Location
Spinal cord
Nerve root
Peripheral nerve
Neuromuscular junction
Muscle
Characteristic Symptoms and Signs Suggestive of Localization to This Region
Bilateral weakness and sensory loss
Bowl and bladder dysfunction
Brown-Sequard syndrome
Upper motor neuron signs
Radiating pain corresponding to a nerve root distribution
Numbness or weakness in a nerve root distribution
Diminish reflex (lower motor neuron signs) in teritory of nerve root
Distal paresthesias, sensory loss, or weakness
Diminish distal reflexes (distal lower motor neuron signs)
Waxing and waning weakness, dysarthria, dysphagia, ptosis, diplopia
Weakness (usually proximal)

11. Common Neurological Symptoms
Headache
Visual Disorder
Loss of Consciousness
Speech Disorder
Motor Disorder
Inco-ordination
Weakness
Involuntary movement
Sensory Disorder
Sphincter Disorder
Lower Cranial Nerve Disorder
Mental Disorder

12. Motor Observation Involuntary Movements Chorea Fasciculation Athetosis
Ballismus
Myoclonus
Tetanus
Fasciculation
Myotonia
Cramp
Tremor

13. Fasciculation

14. Rippling muscle disease

15. Myotonia

16. Muscle Symmetry
Left to Right
Proximal vs. Distal
Atrophy
Pay particular attention to the hands, shoulders, and thighs, hip.
Gait

22. Muscle Tone
Ask the patient to relax.
Flex and extend the
patient's fingers, wrist,
and elbow.
Flex and extend patient's ankle and knee.
There is normally a small, continuous resistance to passive movement.
Observe for decreased (flaccid) or increased (rigid/spastic) tone.

23. Muscle tone

24. Muscle Strength
Test strength by having the patient move against your resistance.
Always compare one side to the other.
Grade strength on a scale from 0 to "out of five"

25. Grading Motor Strength Grade
0/5
No muscle movement
1/5
Visible muscle movement, but no movement at the joint
2/5
Movement at the joint, but not against gravity
3/5
Movement against gravity, but not against added resistance
4/5
Movement against resistance, but less than normal
5/5
Normal strength

26. Squeeze two of your fingers "grip" Finger abduction
Flexion at the elbow
C5, C6, biceps
Extension at the elbow
C6, C7, C8, triceps
Extension at the wrist
C6,C7, C8, radial n
Squeeze two of your fingers "grip"
C7, C8,T1
Finger abduction
C8, T1, ulnar nerve
Opposition of the thumb
C8,T1, median n

27. Flexion at the hip
L2, L3, L4, iliopsoas
Adduction at the hips
L2, L3, L4, adductors
Abduction at the hips
L4, L5, S1, gluteus medius and minimus
Extension at the hips
S1, gluteus maximus

28. Extension at the knee
L2, L3, L4, quadriceps
Flexion at the knee
L4, L5, S1, S2, hamstrings
Dorsiflexion at the ankle
L4, L5
Plantar flexion S1

29. Pronator Drift
Ask the patient to stand for seconds with both arms straight forward, palms up, and eyes closed.
(drift into pronation)
Instruct the patient to keep the arms still while you tap them briskly downward

33. Reflexes Deep Tendon Reflexes
The patient must be relaxed and positioned properly before starting.
Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response.
Reflexes can be reinforced by having the patient perform isometric contraction of other muscles

34. Tendon Reflex Grading Scale Absent 1+ or + Hypoactive 2+ or ++
Reflexes should be graded on a 0 to 4 "plus" scale:
Absent
1+ or +
Hypoactive
2+ or ++
"Normal"
3+ or +++
Hyperactive without clonus
4+ or ++++
Hyperactive with clonus

36. Biceps reflex (C5, C6)
1.The patient's arm should be partially flexed at the elbow with the palm down.
2.Place your thumb or finger firmly on the biceps tendon.
3.Strike your finger with the reflex hammer.
4.You should feel the response even if you can't see it.

37. Triceps reflex (C6, C7)
1.Support the upper arm and let the patient's forearm hang free.
2.Strike the triceps tendon above the elbow with the broad side of the hammer.
3.If the patient is sitting or lying down, flex the patient's arm at the elbow and hold it close to the chest.

38. Brachioradialis reflex (C5, C6)
1.Have the patient rest the forearm on the abdomen or lap.
2.Strike the radius about 1-2 inches above the wrist.
3.Watch for flexion and supination of the forearm

40. Knee reflex (L2,3,4)
Have the patient sit or lie down with the knee flexed.
Strike the patellar tendon just below the patella.
3. Note contraction of
the quadriceps and
extension of the knee
Ankle rerflex (S1, S2)
1.Dorsiflex the foot at the ankle.
2.Strike the Achilles tendon.
3.Watch and feel for plantar flexion at the ankle.

42. Clonus
If the reflexes seem hyperactive, test for ankle clonus: ++
1.Support the knee in a partly flexed position.
2.With the patient relaxed, quickly dorsiflex the foot.
3.Observe for rhythmic oscillations.

43. Abdominal (T8, T9, T10, T11, T12)
1.Use a blunt object such as a key or tongue blade.
2.Stroke the abdomen lightly on each side in an inward and downward direction above (T8, T9, T10) and below the umbilicus (T10, T11, T12).
3.Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus.

44. Plantar Response (Babinski)
1.Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
2.Note movement of the toes, normally flexion (withdrawal).
3.Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.

45. Gait Ask the patient to: 1. Walk across the room, turn and come back
2. Walk heel-to-toe in a straight line
3. Walk on their toes in a straight line
4. Walk on their heels in a straight line
5. Hop in place on each foot
6. Do a shallow knee bend
7. Rise from a sitting position

46. Paraplegia

47. Neuropathic

49. GOWER’S SIGN

50. Cerebellar exam 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.
Interpretation: The patient should be able to do this at a reasonable rate of speed, trace a straight path, and hit the end points accurately. Missing the mark, known as dysmetria, may be indicative of disease.

51. Cerebellar exam Rapid Alternating Finger Movements:
Ask the patient to touch the tips of each finger to the thumb of the same hand.
Test both hands.
Interpretation: The movement should be fluid and accurate. Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease.

52. Cerebellar exam 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.
Interpretation: The movement should be performed with speed and accuracy. Inability to do this, known as dysdiadokinesia, may be indicative of cerebellar disease.

53. Cerebellar exam Heel to Shin Testing:
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.
Intepretation: The movement should trace a straight line along the top of the shin and be done with reasonable speed.

54. Cerebellar exam
Realize that other organ system problems can affect performance of any of these tests. If, for example, the patient is visually impaired, they may not be able to see the target during finger to nose pointing. Alternatively, weakness due to a primary muscle disorder might limit the patient's ability to move a limb in the fashion required for some of the above testing. Thus, other medical and neurological conditions must be taken into account when interpreting cerebellar test results.

55. Cerebellar disease