Motor act is organized by interconnection between

Pyramidal system Extrapyramidal system Cerebellum

Control volutary movements Dampens erratic motions, Control coordination, muscle
and muscle tone maintains muscle tone and tone
purposive movement.

Examination of M o t o r s y s t e m
1. Research of motor function begins with the general survey of extremities and
trunk muscles for revealing:
 Muscular atrophies and their location
 Hypertrophies
 Fibrillation and fasciculation
For definition of muscles atrophies degree, the circumference of extremities is measured
by a centimeter tape from both parties on symmetric places.
2. Investigate volume of active movements in joints of upper and lower extremities
(the volume of movements can be full, limited or movements can absent).
3. Define presence of poverty, slowness of movements (oligo-bradykinesia).
4. Muscular power is investigated by resistance which the patient make to the
doctor’s commands to flex and to extense each extremities. Muscular power is estimated on a
five-score scale.
0– plegia, muscle contractions are absent.
1– weak muscle contractions.
2– full volume of movements in all directions without overcoming the own weight of limbs
3- full volume of movements in all directions. Including movements for overcoming the
own weight of limbs (lifting hands with resistance to doctor power)
4– full movements with decreased poser
5– normal power
5. For revealing of a paresis of extremities check Barre’s probe (ask patient to lift
extremities and keep hands and legs in flexed position during 1 - 1,5 minutes. At presence of a
paresiss legs and hands quickly gets tired and fall.
6. Presence ankylosis and changes of a muscular tone (hypotonia, atonia, hypertonia)
reveal at passive movements in all joints of extremities at the moment of a full relaxation of
muscles.
7. Gait examination.
Ask the patient make some steps with open eyes, and eyes closed, to turn the body quickly,
to stop, to walk straightly on line.Pay attention to position of feet during walking, on stability of
patient, on deviation aside, on presence accompanied movements of hands and feet. It is
necessary to note a kind of pathological gait (ataxic, spastic gait, tabetic gait, doll (shuffling
gait), steppage gait)
8. Check Normal and pathological Reflexes.

Normal reflexes
During examination of reflexes pay attention to its dеcrease (hyperreflexia), increase
(hyperreflecxia) and asymmetry of them (anyzoreflexia).
I. Tendon:
1. Biceps reflex is examined by blow of hammer on biceps brachialis muscle tendon above the
elbow joint. Response : contraction of muscle and flexion in elbow joint.
Reflex arch: С5 - С6 segments.
2. Triceps reflex is caused by hammer blow on tendon of triceps muscle. Response: contraction
of this muscle and extension of forearm and elbow joint. Arch of reflex С7-С8 a segment.
3. Knee reflex is caused by hammer blow on knee tendon, patellar ligament lower the knee
patellar. Response: contraction of the muscle quadriceps, femoris and extension of shank. Arch –
n. Femoralis, L3-L4.
4. Ankle reflex is caused by hammer blow on ankle tendone. Response – contraction of m.
Gastrocnemius and flexion of foot. Arch – n. tibialis, S1-S2.
II. Periostal:
1. Superciliary reflex - tip of hammer on the border of superciliary arch. Response: closing the
eyes (m. Orbicularis oculi). Arch: n. Ophthalmicus, I branch trigeminal nerve, sensoruy
nuclei of trigeminal nerve, motor nuclei of facial nerve, n.facialis.
2. Mandibular reflex - tip of neurological hammer on the chin or on lower part of mandibula
with half-opened mouth. Response: contraction of masseter muscles (n.masseter), which
provoke closure of mandibula. Arch: sensory tract of n. Mandibularis (III branch of
trigeminal nerve), sensory nuclei of trigeminal nerve. This reflex can increase in
pseudobulbar paralise.
3. Arm (scapulo-humeral) reflex – after blowing of hammer on internal border of scapula will
be response: putting and rotation the arm ectad, which must hang down freely
4. Carporadial reflex - blowing of hammer on the styloid processus of radius bone. Response:
flexing in elbow joint, pronation and flexion of fingers, mostly expressed pronation. Arch:
C5, C6, CV7, muscles pronatores, flexors of fingers, m. Brachioraialis, m. Biceps, n.
Medianus, radialis, musculocutaneus.
III. Skin
1. Superficial abdominal reflexes :
 upper (epigastral) – irritation abdominal skin on the level of subcostal arch in
direction from peripheria to center provoke response: contraction of superficial
abdominal muscles. Arch: Th7-Th8
 middle (mesogastral) – irritation of abdominal skin on the level of umbilicus in
direction from peripheria to center provoke the same response, Th9-Th10
 lower (hypogastral) – irritation of abdominal skin on the level of inguinal
ligament in direction from peripheria to center provoke the same response, TH11-
TH12
2. Plantar reflex – as answer on touching by hammer shaft on the lateral part of plantar
surface from down to up provoke response: flexion of foot fingers. Arch: n. Ischiadicus,
L5-S1.
3. Cremaster reflex – provoke by touching irritation of medical surface of scrotum.
Response: contraction of m.cremasterius and tightening up of testicles. Arch: n.
Genitofemoralis, L1-L2.
4. Anal reflexes: prickling the skin near anus provoke the response: contraction of round
anal muscle. Arch: n. Coccygei, S4-S5.
IV. Reflexes from mucous membranous
1. Swallow reflex – take piece of paper or spatula and touch posterior surface of throat.
Response: swallowing movements, coughing, vomiting movements. Arch: sensory tract
and nucleuses of IX and X intracranial nerves (n. Glossopharyngeus and n. Vagus, motor
nucleuses of tracts of the same nerves.
2. Palatine reflex – as a result of touching of soft palatine. Response: lifting the soft palatine
and uvula. Diagnostic value - absence of this reflex in one side. Arch: the same like
swallow.
3. Corneal reflex – as a result of carefully touching by cotton of cornea surface laterrally
from pupil. Response: closure of eyes.
4. Conjunctival - touching the conjunctive. Response: closure of eyes. Arch: like
supraciliary reflex.

Pathological reflexes
Extensor group:
1. Babinsky reflex (opposite plantar reflex) – provoke like palntar reflex touching by hammer
shaft on the lateral part of plantar surface from down to up. Response: extension of 1s finger (big
toe) and fan-shaped opening of another fingers. This reflex is early appears during disconnection
between break function of cortex and low lying structers: spinal cord, brainstem, when lesion is
in upper (1st) neuron and it’s axon.
2. Oppengeim reflex - to provoke this reflex doctor use two fingers: 1st finger and dystal phalanx
of 2nd with slicing movement in direction from knee on the frontoexternal part of tibia till upper
surface of foot. Response: like during Babinsky reflex.
3. Gordon reflex –during pressing on the mass of gastrocnemius muscle will be the same
response.
4. Sheffer reflex – during pressing on anckle tendon on paralysing limb. Response the same like
during Babynsky reflex.
Flexor group:
A) From lower limb:
1. Rossolimo - short tipping by fingers of doctor on the inferior surface of fingers of foot
provoke it’s dystal flexion.
2. Jukovsky – short tipping of hammer on the plantar surface of patient foot on the base of
fingers provoke response: dystal flexion of foot fingers.
3. Bechterev-Mendel reflex the first – blowing by neurological hammer on the superficial
surface of foot near fingers phalanges provoke response: dystal flexion of fingers.
4. Bechterev-Mendel reflex the second - blowing by neurological hammer on the superficial
surface of foot near ankle joint provoke response: dystal flexion of fingers.
B) From upper limb:
1. Rossolimo - short tipping by fingers of doctor on the inferior surface of patient fingers
provoke it’s dystal flexion.
2. Jukovsky – short tipping of hammer on the plantar surface of hand on the base of fingers
provoke response: dystal flexion of fingers.
3. Bechterev-Mendel reflex the first – blowing by neurological hammer on the superficial
surface of hand near fingers phalanges provoke response: dystal flexion of fingers.
4. Bechterev-Mendel reflex the second - blowing by neurological hammer on the superficial
surface of hand near carporadial joint provoke response: dystal flexion of fingers.
Oral automatism reflexes
1. Haustellate reflex – in response on touching the lips or without provokation patient
realize haustellate, chewing movements.
2. Nasolabial reflex – when doctor tip by neurological hammer on the surface near lips,
patient involuntary tube his lips.
3. Palmar-mental reflex (Marinesku-Radovichi) – if doctor irritate by touching movements
the palmar surface of hand, will be response: contraction of chin muscles.
4. Dystant-oral reflex – if doctor simply move the hammer or his finger in direction of lips,
patient involuntary contract the muscles of lips and chin.
Protective spinal automatism reflexes
1. Mary-Fua reflex - force plantar flexion of foot fingers provoke involuntary flexion of
paralityc leg in knee and hip joint.
2. Davydenkov reflex – the same reaction as a response on irritation the lateral surface of
hip of paralytic leg
3. Shortened reflex from upper limb – if doctor irritate by touching the trunk of patient with
spinal cord trauma (upper segments) it provoke flexion in ulnar and radial joints in
paralytic upper limbs and putting this hand on the chest.

Segment of spinal cord – area of spinal cord with pair of incoming and outcoming rootes, which
innervate only 1 dermatom.
 base unit of N.S.
Reflex – response of organism on external irritation
 functional unit of N.S.
Person have 31-32 segments
C8 –cervical
Th12 – thoracal
L5- lumbal
S5 – sacral
Co – coccigei
 Relation segments of spinal cord to skin projection:

C1-C4 Neck, posterior surface hairy part of head to the middle of parietal bone
C4 Clavicula
C5-Th1,2 Cervical enlargement (bulk) – innervate upper limbs
Th2 Axillary crease
Th5 At nipple level
Th7 Inferior angle of scapula
Th10 At umbilicus level
Th12 At inguinal ligament
L1-S2 Lumbar enlargement (bulk) – innervate lower limbs
S3-S5 Pelvic organs, perineum

Relations segments to vertebras:

C1-C4 – correspond to vertebras

C5-C8 – for 1 vertebra above
Th1-Th6 - for 2 vertebra above
Th7 and below - for 3 vertebra above

Why do we need this: if patient has lower paraparesis, we thought aboyt lesion L1-S2 level, that
is why we can make target X-ray for 3 vertebra above i.e  Th10

Muscle tone increase in case of lesion:

1. First neuron of pyramidal tract (clasp-knife, spastic type)
2. Pallidum (cog wheel, plastic type)

Muscle tone decrease in case of lesion:

1. II neuron of pyramidal tract
2. Cerebellum
3. Striatum
4. Posterior white column

Features Central paralyze Peripheral paralyze

Lesion of 1st neuron of PT 2nd neuron of PT
Normal Increased (hyperreflexia) Decreased (hyporeflexia)
reflexes
Muscle tone Increased (hypertonia, spastic type, Decreased (hypotonia)
“clasp knife” phenomenon)
Atrophy of - +
muscles
Fibrillation, - +
fasciculation
of muscles
Pathological + -
reflexes
Сlonuses + -
 Extrapyramidal system
Functions:
1. Responds for purposive movements.
2. Regulate muscle tone
3. Respond for nonvoluntary movements
Consists of:
1. paired subcortical masses or nucleis of grey matter, which are called –Basal ganglia.

Divides into 2 groups:

1. Pallidum - activate
 Globus pallidum
 Subthalamic nulei.
 Substancia nigra.
 Red nuclei
2. Striatum - extinguish
 Caudate nuclei.
 Putamen.

The lesion of pallidum produce Parkinson syndrome (amyostatic, hypertonico-

hypokinetic, akinetico-ridigity)

1. Rigidity= Stiffness – a state when muscle tone increased in plastic type.

We felt stiffness when passively moving a limb. This resistance is present to the same degree
throughout the full range of movement, affecting flexor and extensor muscle groups equally
and described as Plastic rigidity.
Rigidity predominates in the flexor muscles of the neck, trunk and limbs and result is Flexed-
Bent Posture.

2. TREMOR at rest is pill rolling, the thumb moving rhythmically backwards and
forwards on the palm of the hand. It begins unilaterally in the upper limbs and spread to
all four limbs.
It occurs- at rest
Decrease -with movement
Disappear- during sleep.

3. Bradykinesia
This slowness or paucity of movement affects facial muscles of expressions as well as
muscles of mastication speech, voluntary swallowing and muscles of the trunk and limbs.

Dysarthria, dysphagia and a slow deliberate gait with little associated movement result.

Tremor, ridigity and bradykinesia deteriorate (make worse) at the some time, affecting every
aspect of patient life.

4. Micrographia – handwriting reduces in size.

5. Mask-like expressionless face due to bradykinesia.

6. The gait become shuffling and festinant – small rapid steps to keep up with the centre of
gravity and the posture more flexed.

7. Dysfunction of autonomic nervous system

 greasy skin (seborrhoea )
 excessive (much) sweating
  drooling
 postural hypotension

8. Depression, drug-induced confusional states , inertioin (due to limbiki-reticular

system, which respond for emotions).

9. Propultion – involuntary jerky movements to ahead

Lateropultion – to the sides
Retropultion – to the back

10. Aheirokinesis – disappearance of cooperation movements

Akinesia due to constant increased muscle tone.

We observe Parkinson syndrome in next cases:

1. drug induced
2. post traumatic
3. vascular disease
4. infections
5. miscellaneous (hydrocephalus, paraneoplastic)

Hypotonic-hyperkinetic syndrome

Hyperkinesis – an involuntary irregular jerking movements affecting limb and axial muscle
groups
Disappear –during sleeping
Increase –with movements, emotions
1. Choreic hyperkinesis – irregular repetitive jerking movement affecting limbs and axial
muscles. It is like dancing, clown around

Patient close eyes – put out his tongue – make grimace – lift his arm

2. Athethosis – irregular repetitive writhing movements affecting face, distal part of limbs
Increase with emotions

3. Dystonia – slow sustained abnormal movement, corkscrew movement of trunk around

his own axis

4. Spasmodic torticollis (wry neck) –unilateral deviation of the head due to dystonic
contraction of one sternomastoid muscles.

5. Hemiballismus-unilateral violent jerking of the limb in major proximal group of muscles

(like wing beat)

6. Mioclonus –fast shock-like jerks in major muscles

7. Mioritmus – stereotype short regular contractions of minor muscles( tongue, palatine,

diaphragm). Does not depend on movements

In the presence of hyperkinesis it is necessary to describe their character, location, a rhythm, rate,
a variety or stereotype, degree of expressiveness throughout day, the exacerbating reasons,
whether they disappear in a dream.
 Cerebellum
Lies in the posterior fossa, posterior to the brain stem, separated from the cerebrum above
by the tentorium cerebelli.
The cerebellum consists of 2 laterally placed hemispheres and the midline structure –
vermis.
Consist of
1. Grey matter (cortex and 4 pairs of nucleus)
2. White matter (afferent and efferent nervous fibres, which form peduncles)
 Superior cerebellar peduncle -- midbrain (Govers tract -2crossed)
 Middle peduncle – pons
 Inferior peduncle –medulla (Flecsig tract – not crossed)
Hemispheres coordinate limb movements
Vermis - mucsles of head, neck and trunk

Clinical signs of cerebellar dysfunction

The common, important clinical signs of cerebellar dysfunction are listed below:
• Nystagmus.
• Dysarthria: the muscles of voice production and speech lack coordination so that sudden
irregular changes in volume and timing occur, i.e. scanning or staccato speech.
• Upper limbs: ataxia and intention tremor, best seen in movement directed towards a restricted
target, e.g. the finger–nose test;
 Dysdiadochokinesia, i.e. slow, inaccurate, rapid alternating movements.
• Lower limbs: ataxia and intention tremor, dysmetria best seen in the heel–knee–shin test.
• Gait and stance ataxia, especially if the patient is asked to walk heel to toe, or to stand still on
one leg.
• Hypotonia, though a feature of cerebellar lesions, is not very useful in clinical practice.

!!! Cerebellar representation is ipsilateral, so a left cerebellar hemisphere lesion will produce
nystagmus which is of greater amplitude when the patient looks to the left, ataxia which is
more evident in the left limbs, and a tendency to deviate or fall to the left when standing or
walking.

Vermis Hemispheres
Static ataxia (trunk) Dynamic ataxia (distal part of limbs)
 Romberg test  Dysdiadochokinesis
(tends to fall  Intention tremor, dysmetria ( finger-nose test, heel-knee-
forward) shin test)
 Romberg test (tends to fall to the side of affected
hemisphere)

Diffuse muscle hypotonia Muscle hypotonia on ipsilateral part

Drunken gait (broad based Asynergia
and reeling)  Babinski
 Stuart –Holms
Nystagmus , megalographia, scanning speech

Causes of cerebellar malfunction

The common causes of cerebellar malfunction are:
• cerebrovascular disease;
• multiple sclerosis;
• drugs, especially anticonvulsant intoxication;
• alcohol, acute intoxication.
Rarer cerebellar lesions include:
• posterior fossa tumours;
• cerebellar abscess, usually secondary to otitis media;
• cerebellar degeneration, either hereditary (e.g. Friedreich’s
ataxia and autosomal dominant cerebellar ataxia), alcohol
induced, or paraneoplastic;
• Arnold–Chiari malformation (the cerebellum and medulla
are unusually low in relation to the foramen magnum);
• hypothyroidism.

Examination of coordination
Romberg` test - in standing position, feet together, having extended hands before itself. In the
presence of static ataxia, imbalance or falling down are observed.
Finger - nose test – ask patient to close eyes, to take a hand aside and to get with index finger to
a tip of the nose.
Heel-knee test – ask patient laying on a back to lift a foot, to touch by a heel other foot knee and
to slice downwards.
At all tests pay attention to acurateness of performance, to dysmetria, and intention tremor.

Asynergya Babinski test - Patient laying in spine position with the crossed on chest hands
should sit down. If asynergya is present patient legs’ll be lifted.
Dysdiadochokinesis - ask patient to pronate and supinate his stretched hands. If the test is
positive one hand will be behind.
During the examination definitе the type of ataxia (static,dynamic).