neurology ( motor system examination and reflexes )

1. neurology
Motor system Examination
Dr mohamed rizk khodair
lecturer of neurology
October 6 university
Mohamedrizk.med@edu.edu.eg
‫والجراحة‬ ‫الطب‬ ‫كلية‬

2. The motor system evaluation is divided into the following
Inspection :
Body positioning
Muscle waste ( wasting or hypertrophy )
Involuntary movements, fasciculation .
Skeletal deformities
Trophic changes

3. Body positioning :

4. Muscle wasting
Distribution :
Focal or generalized (proximal or distal)
Unilateral or bilateral
Symmetrical or not

5. Muscle wasting
pseudo hypertrophy

6. Skeletal deformities
Look for skeletal deformities : pes cavus , scoliosis

7. Muscle inspections
Fasciculation : examine the bulky muscle
Trophic changes

8. Muscle inspections
abnormal movements
• Distribution
• Rest , postural or action
• Frequency
• Amplitude
• Rhythmic or not
• What increase or decrease them

9. Assessment of muscle tone
A: upper limbs :
Shoulder : Gower’s method
Elbow : passive flexion and extension
Wrist : shaking , passive flexion and extension
B: lower limbs :
Hip : rolling
Knee : hooking , passive flexion and extension
Ankle : shaking , passive flexion and extension

10. Abnormal muscle tone
• Hypotonia
• Hypertonia : Spasticity , rigidity (cogwheel & lead pipe )
• Dystonia
• Myotonia
• Catatonia
• Stiffness ( meningeal irritation , stiff person syndrome )

11. Muscle power
• Power or strength is tested comparing the patient’s strength against your
own
• Compare one side to the other
• Grade strength using the medical research council scale

12. Upper limb
1. Shoulder ( adduction , abduction , flexion, extension, lateral rotators, medial rotators, serratus
anterior )
2. Elbow ( flexion and extension )
3. Wrist ( flexion and extension )
4. Hand ( thumb, interossesi, lumbricals )

13. Lower limb
1. Hip : flexion , extension, abduction, adduction
2. Knee : flexion , extension
3. Ankle : dorsiflexion , plantarflexion ,inversion , eversion
Don’t forget the trunk muscle ( abdominal and back muscle )

14. Gait abnormality

15. Coordination :
Upper limb
• With opened and closed eyes : finger to nose , finger to finger test , finger to doctor’s test
• Dysdiadokokinesia : inability to perform rapid alternating movement (pronation and supination )
• Rebound phenomenon : with sudden release of flexed elbow
• Buttoning or unbuttoning test : earliest sign
Lower limb :
• With opened and closed eye : heel to knee test.
• Standing : swaying truncal ataxia
• Walking along straight line
• Romberg sign

16. You must continue searching for all signs of
cerebellum
• Eye : nystagmus
• Speech staccato
• Neck : nodding
• Buttoning and non buttoning
• Rebound phenomenon
• Heel toes walking

17. Reflexes
Deep reflexes :
Upper limb ( Biceps reflex c5,6 , Brachioradialis reflex c5,6, Triceps reflex c6,7,
Supraspinatus reflex ,Finger reflex )
Lower limb ( knee reflex, ankle reflex, patellar reflex, adductor reflex )
Superficial reflexes
Planter reflexes ( babiniski method ,chaddok ,baradah openhinme , Gordon , Schaefer)
Abdominal reflexes, cremastric reflex , gluteal reflex , anal reflexes

18. Rate the reflex with following scale:
1. Sustained clonus 5+
2. Very brisk , hyperreflexia with clonus 4+
3. Brisker or more reflexive than normally 3+
4. Normal +2
5. Low normal or diminished 1+
6. A reflex that only elicited with reinforcement 0.5

19. Reflexes

20. Superficial reflexes

21. Abdominal reflex

22. Trömner reflex Mayer reflex
Reflexes: Pathological
Hoffman's sign (reflex): hold the patients partially extended middle finger by
your index finger and thumb, then flick it sharply by other hand followed by
sudden release~ flexion of the thumb (&adduction) and other fingers .
Tromner sign: hold the patients partially extended middle finger, letting the
hand dangle, then with the other hand flick the finger pad (similar response to
Hoffmann sign).
Wartenberg's thumb adduction sign : examiner links his flexed fingers with
patients' flexed fingers, then both flex their fingers further against each other's
resistance -> normally, thumb extends, while in pyramidal tract lesions ->
thumb adducts & flexes.

23. Frontal release signs (FRS):
• They are normally present in the developing nervous system, but disappear with maturation, and include palmomental
reflex (PMR), grasp, snout, sucking, head retraction and others.
• They occur with severe diffuse frontal lobes lesions e.g., dementias, diffuse encephalopathy, or head injury.
Guide to Neurological Examination
1. Grasp (forced grasping) reflex: gentle touching patients palm or trying to extend patients fingers - > patients' finger
flexion.
3.Palmomental reflex (PMR), or palm-chin reflex: scratching the palm of the ipsilateral hand especially thenar eminence ~
contraction of the mentalis and orbicularis oris ~ wrinkling of the chin with slight retraction of mouth.
It is exaggerated with frontal lobe lesions.
4. The orbicularis oris (snout): pressing firmly backward on the philtrum of the upper lip ~ puckering and protrusion of the
lips.
5. The sucking reflex).

24. Lower-Limb Pathologic Reflexes:
1. Babinski sign : the most important of pathological reflexes.
2. Flexion plantar responses:
- Plantar grasp reflex: similar to grasp reflex.
- Plantar muscle reflex: comparable to finger flexor reflex
- Rossolimo's sign: tapping the ball of foot or plantar surface of toes ~
plantar flexion.
3. Crossed extensor reflex: stimulation of the foot or leg on one side ~
flexion of that leg with extension of the other leg (with severe myelopathy).
4. Extensor thrust response: pressure applied to the foot of the passively flexed leg causes reflex extension.
5. The mass reflex (of Riddoch) : with severe myelopathy, stimulation below the spinal level -> massive
response, including leg flexion, abdominal wall contractions, evacuation of the bladder and bowel, sweating,
reflex erythema, pilomotor responses, and hypertension ± priapism and ejaculation.

25. The typical reflex pattern with UMNL is exaggerated DTRs, lost superficial
reflexes, and emergence of pathologic reflexes.

26. Reflexes: Pathological Postural Reflex
• Flexion withdrawal reflex:
• Decorticated:
• Decerebrated:

27. Thank you
Mohamedrizk.med@edu.edu.eg