MOTOR_EXAM

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EXAMINATION OF THEEXAMINATION OF THE

CENTRAL NERVOUSCENTRAL NERVOUS

SYSTEM(CNS)SYSTEM(CNS)

MOTOR NERVOUS SYSTEMMOTOR NERVOUS SYSTEM

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CNS EXAMINATIONCNS EXAMINATION

Higher Mental Functions (HMF)Higher Mental Functions (HMF)

Examination of the Unconscious PatientExamination of the Unconscious Patient

Cranial Nerves ExaminationCranial Nerves Examination Examination of the Motor Nervous SystemExamination of the Motor Nervous System

Examination of the Sensory Nervous SystemExamination of the Sensory Nervous System

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CNS EXAMCNS EXAM

The nervous system is broadly divided into theThe nervous system is broadly divided into the

central and peripheral nervous systemscentral and peripheral nervous systems

The CNS consists of the Brain & Spinal cordThe CNS consists of the Brain & Spinal cord

The Peripheral nervous system consists of theThe Peripheral nervous system consists of theperipheral nervesperipheral nerves

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BRAINBRAIN

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SPINAL CORDSPINAL CORD

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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM

To determine if there are any abnormalitiesTo determine if there are any abnormalities

To determine the location of such abnormalitiesTo determine the location of such abnormalities

To determine the degree of such abnormalitiesTo determine the degree of such abnormalities

i.e. to make a diagnosis, determine the site of thei.e. to make a diagnosis, determine the site of thelesion and formulate a management planlesion and formulate a management plan

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1.1. BulkBulk

2.2. PowerPower

3.3. ToneTone4.4. Deep Tendon Reflexes (DTRs)Deep Tendon Reflexes (DTRs)

5.5. Abdominal & Plantar reflexesAbdominal & Plantar reflexes

6.6. CoordinationCoordination7.7. GaitGait

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BULKBULK

IncreasedIncreased

NormalNormal

DecreasedDecreased

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TONETONE

Hypertonia (increased tone): lead pipe/claspHypertonia (increased tone): lead pipe/clasp

knifeknife Normal toneNormal tone

Hypotonia (flaccidity)Hypotonia (flaccidity)

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POWER (graded 0 to V)POWER (graded 0 to V)

0 = absent power0 = absent power

I = movement when gravity is eliminatedI = movement when gravity is eliminated II = movement against gravity but not againstII = movement against gravity but not against

the resistance of the examinerthe resistance of the examiner

III = movement against mild resistanceIII = movement against mild resistance

IV = movement against moderate resistanceIV = movement against moderate resistance

V = full powerV = full power

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DEEP TENDON REFLEXES (DTRs)DEEP TENDON REFLEXES (DTRs)

Hypereflexia (+++)Hypereflexia (+++)

Normoreflexia (++)Normoreflexia (++) Hyporeflexia (+)Hyporeflexia (+)

Areflexia (absent reflex)Areflexia (absent reflex)

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PLANTAR REFLEXPLANTAR REFLEX

Elicited by stroking the sole of footElicited by stroking the sole of foot

A normal response involves flexion (downwardA normal response involves flexion (downwardmovement) of the great toemovement) of the great toe

Abnormal response involves extension (upwardAbnormal response involves extension (upward

movement of the great toe) +/movement of the great toe) +/-- fanning out offanning out ofthe other toes (Babinski sign)the other toes (Babinski sign)

Abnormal response seen in UMN lesionsAbnormal response seen in UMN lesions

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ABDOMINAL REFLEX:ABDOMINAL REFLEX:

Elicited by stroking the abdominal wall fromElicited by stroking the abdominal wall from

laterally towards the umbilicus in 4 quadrants.laterally towards the umbilicus in 4 quadrants.1.1. Absent in UMN lesionAbsent in UMN lesion

2.2. Decreased in LMN lesionDecreased in LMN lesion

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UPPER MOTOR NEURON LESIONSUPPER MOTOR NEURON LESIONS

Seen in lesions (disorders) ofSeen in lesions (disorders) of Brain & Spinal cord:Brain & Spinal cord:

1.1. WeaknessWeakness

2.2. Wasting (mild)Wasting (mild)

3.3. Hypertonia (clasp knife)Hypertonia (clasp knife)

4.4. HypereflexiaHypereflexia

5.5. Babinski signBabinski sign

6.6. ClonusClonus

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LOWER MOTOR LESIONSLOWER MOTOR LESIONS

Seen in lesions of theSeen in lesions of the peripheralperipheral nerves:nerves:

1.1. Loss of powerLoss of power2.2. Marked muscle wasting (decreased bulk)Marked muscle wasting (decreased bulk)

3.3. HypotoniaHypotonia

4.4. AreflexiaAreflexia5.5. FasciculationsFasciculations

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Nerve Root Values (Upper Limb Power):Nerve Root Values (Upper Limb Power):

1.1. Shoulder abduction (C5,6)Shoulder abduction (C5,6)

2.2. Shoulder adduction (C5,6,7)Shoulder adduction (C5,6,7)3.3. Elbow flexion (C5,6)Elbow flexion (C5,6)

4.4. Elbow extension (C7,8)Elbow extension (C7,8)

5.5. Wrist flexion (C6,7,8,T1)Wrist flexion (C6,7,8,T1)

6.6. Wrist extension (C6,7,8)Wrist extension (C6,7,8)

7.7. Finger abduction & adduction (C8, T1)Finger abduction & adduction (C8, T1)

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Upper LimbsUpper Limbs

ShoulderShoulderabductionabduction

Deltoid C5/6Deltoid C5/6

Axillary NerveAxillary Nerve

ShoulderShoulderadductionadduction

Pectoralis major C6/7Pectoralis major C6/7

Lattisimus dorsi C7Lattisimus dorsi C7

WristWrist

extensionextension

Extensor carpi radialisExtensor carpi radialis

longuslongus

Extensor carpi ulnarisExtensor carpi ulnaris

C6/7/8C6/7/8

Finger flexion/Finger flexion/Abduction/Abduction/

Adduction/Adduction/ThumbThumbmovementsmovements

Radial/Ulnar/MedianRadial/Ulnar/Median

nerves C8/T1nerves C8/T1

ElbowElbowflexionflexion

Biceps:C5/6Biceps:C5/6

MusculocutaneousMusculocutaneous

nervenerve

ElbowElbowextensionextension

Triceps C7/8Triceps C7/8

Radial nerveRadial nerve

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DTRs Root Values (Upper Limb)DTRs Root Values (Upper Limb)

1.1. BicepsBiceps -- C5,6C5,6

2.2. SupinatorSupinator -- C5,6C5,63.3. TricepsTriceps C6, 7C6, 7

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Nerve Root Values (Lower Limb Power):Nerve Root Values (Lower Limb Power):

Hip flexion (L1/2)Hip flexion (L1/2)

Hip extension (L5,S1)Hip extension (L5,S1)

Hip abduction (L4,5,S1)Hip abduction (L4,5,S1)

Hip adduction (L2,3,4)Hip adduction (L2,3,4)

Knee flexion (L5,S1,2)Knee flexion (L5,S1,2)

Knee extension (L2,3,4)Knee extension (L2,3,4)

Ankle (plantar) flexion (S1,2)Ankle (plantar) flexion (S1,2)

Ankle extensionAnkle extension dorsiflexion (L4,5)dorsiflexion (L4,5)

Inversion (L4,5)Inversion (L4,5)

Eversion (L5, S1)Eversion (L5, S1)

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Lower LimbsLower Limbs

Hip flexionHip flexion IliopsoasIliopsoas

L2/3L2/3

FemoralFemoralnervenerve

HipHipextensionextension

GluteiGlutei

L4/5/S1L4/5/S1

GlutealGlutealnervesnerves

HipHip

abductionabduction

Glutei + TensorGlutei + Tensorfascia lata L4/5 S1fascia lata L4/5 S1

HipHip

adductionadduction

AdductorsAdductors

L2/3/4L2/3/4

Obturator nerveObturator nerve

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Lower LimbsLower Limbs

Knee flexionKnee flexion HamstringsHamstringsL5/S1L5/S1

Sciatic nerveSciatic nerve

KneeKneeextensionextension

QuadricepsQuadriceps

L3/4L3/4

Femoral nerveFemoral nerve

AnkleAnkle

dorsiflexiondorsiflexion

Tibialis anteriorTibialis anterior

Extensor hallucisExtensor hallucislonguslongus

L4/5L4/5

Peronial div. ofPeronial div. ofsciatic nervesciatic nerve

AnkleAnkle

plantarplantarflexionflexion

Gastrocnemius,Gastrocnemius,

Tibialis posteriorTibialis posteriorS1S1

Tibial div. ofTibial div. ofsciatic nervesciatic nerve

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DTRs Root value (lower limb)DTRs Root value (lower limb)

1.1. Knee jerkKnee jerk L2,3,4L2,3,4

2.2. Ankle jerkAnkle jerk -- L5,S1L5,S1

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Coordination:Coordination:

1.1. FingerFinger--Nose testNose test

2.2. HeelHeel--Shin testShin test

3.3. Rapid alternating movementsRapid alternating movements

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EXAMINATION OF GAITEXAMINATION OF GAIT

1.1. StationStation

2.2. TurningTurning3.3. TandemTandem

4.4. Heel walkingHeel walking

5.5. Toe walkingToe walking6.6. RhombergsRhombergs

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MOTOR_EXAM