Done by : Dima Atmeh

Esraa Nahleh
Shereen Abu seif
a) THE MOTOR SYSTEM

b) Assess the motor system under the following

headings:
c) 1 ) inspection and palpation of muscles
d) 2 ) assessment of tone
e) 3 ) testing movement and power (strength )
f) 4 ) examination of reflexes
g) 5 ) testing coordination.
• UPPER MOTOR NEURONE SIGNS (everything up (tone , DTRs, toes)) .
• Indicate that the lesion isabove the anterior horn cell of the spinal cord or motor
nuclei of the cranial nerves.
• LOWER MOTOR NEURONE SIGNS (everything lowered (less muscle mass, muscle
tone, reflexes, downgoing toes)).
• Indicate that the lesion is either in the anterior horn cell or distal to the
anterior horn cell (i.e. anterior horn cell, root, plexus, peripheral nerve).
1 ) Inspection and palpation of the muscles

• Examination sequence
• Completely expose the patient while keeping the patient’s comfort and dignity.
• Note deformities .
• Look for “ SWIFT “ ( inspecting both proximally and distally ) :
Scars , Wasting of muscles , Involuntary movements , Fasciculations and Tremor .

• Fasciculation ( muscle twitch ) a small, local, involuntary muscle contraction and

relaxation which may be visible under the skin ( seen, not felt ) .
2 ) Tone : the resistance felt by the examiner when moving a joint passively.
• Hypotonia (decreased muscle tone) or hypertonia (increased) suggest a lower or
upper motor neurone lesion respectively.
• Hypertonia There are two types of hypertonia: spasticity and rigidity.
Spasticity Rigidity

Stroke Parkinson

More resistance in one direction the other direction , More Same resistance in all directions
tone in initial part of movement – “Clasp knife spasticity”
It is velocity dependent (i.e. more noticeable with fast Not velocity dependent – does not vary with speed of
movements) movement of muscle groups involved

•Clonus is a rhythmic series of contractions evoked by

sudden stretch of the muscle and tendon .
• Unsustained (<6 beats) clonus may be physiological.
• Examination sequence

• Ask the patient to lie supine on the examination couch, and to

relax and ‘go floppy’. Enquire about any painful joints or limitations of movement
before proceeding.
• Passively move each joint tested it’s full range of motion as possible, both
slowly and quickly in all anatomically possible directions. Be unpredictable with
these movements, both in direction and speed, to prevent the patient actively
moving with you; you want to assess passive tone.
• Upper limb
• Hold the patient’s hand as if shaking hands, using your other hand to support his elbow.
Assess tone at the wrist and elbow.
(Move the wrist through its full range of motion , Pronate and supinate the forearm , Flex
and extend the elbow joint )

Lower limb
• Roll the leg from side to side,
•Briskly lift the knee into a flexed position,
observing the movement of the foot .
• Ankle clonus
•Support the patient’s leg, with both the knee and ankle resting
in 90° flexion.
•Briskly dorsiflex and partially evert the foot, sustaining the
pressure . Clonus is felt as repeated beats of
dorsiflexion/plantar flexion.
Power ( The following is a test ) 3
of some of the main movements
of the limbs, sufficient to show most pathology.)
• Examination sequence
• Test upper limb power
with the patient sitting on the edge of
the couch.
• Shoulders

• ABduction (C5) – “Don’t let me push

your shoulders down”
• ADduction (C6/7) – “Don’t let me push
your shoulders up ”
•
• Elbow
• Flexion (C5/6) – “Don’t let me pull your
arm away from you”
• Extension (C7) – “Don’t let me push your
arm towards you”

• Fingers
•Finger ABduction (T1) – “Spread your fingers
• Test lower limb power with the patient reclining / lying down .
• Hip
•Flexion (L1/2) – “raise your leg off the bed and
stop me from pushing it down”
• Extension (L5/S1) – “stop me from
lifting your leg off the bed”
• Knee
• Flexion (S1) – “bend your knee and stop me
from straightening it”
• Extension (L3/4) – “kick out your leg / straighten
the leg against my hand”
• Ankle
• Dorsiflexion (L4) – “keep your legs flat on the bed…bend your foot up towards
your face…don’t let me push it down “
 Deep tendon reflexes ) 4 •
is the involuntary contraction of a muscle
. in response to stretch

• Hyperreflexia (abnormally brisk reflexes) is a sign of upper motor neurone damage. Diminished or absent jerks are
most commonly due to lower motor neurone lesions.
• Examination sequence
• Ask the patient to lie supine on the examination couch with the limbs exposed. He should be as relaxed and
comfortable as possible, as anxiety and pain can cause an increased response
• Flex your wrist and allow the weight of the tendon hammer head to determine the strength of the blow. Strike the
tendon, not the muscle or bone.
• Record the response as: increased , normal , diminished , present only with reinforcement , absent.
• Reinforcement. If the patient’s reflexes are symmetrically diminished or absent, use reinforcement, a technique
involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity .
• To reinforce upper limb reflexes, ask the patient to clench the teeth or to make a fist with the
contralateral hand. The patient should relax between repeated attempts. Strike the tendon immediately
after your command to the patient.
• For Lower limb reflexes, ask the patient to interlock the fingers and pull one hand against the other on
your command, immediately before you strike the tendon (Jendrassik’s manoeuvre)
Upper limb
1. Biceps reflex (C5) – located in the antecubital fossa
• 2. Triceps reflex (C7) – place forearm rested at 90º flexion
• 3. Supinator reflex (C6) – located 10cm proximal to base of the thumb

• Hoffmann’s reflex
• Place your right index finger under the distal interphalangeal joint of the patient’s middle finger.
• Use your right thumb to flick the patient’s finger downwards.
• Look for any reflex flexion of the patient’s thumb
• Finger jerk
•Place your middle and index fingers
across the palmar surface
of the patient’s proximal phalanges.
• Tap your own fingers with the
hammer.
• Watch for flexion of the patient’s
• Lower limb
• 1. Knee jerk (L3/4)
• 2. Ankle jerk (S1)

• 3. Plantar reflex (S1):

• Run a blunt object along the lateral edge of the sole of the foot, moving towards
the little toe .
• Observe the great toe
• Normal result = Flexion of the great toe and flexion of the other toes
• Abnormal (Babinski sign) = Extension of the great toe and spread of the other
toes – upper motor neuron lesion
Coordination ) 5
•Performing complex movements
smoothly and efficiently depends upon
intact sensory and motor function
and an intact cerebellum.
Upper limb

• Finger to nose test

• 1. Ask the patient to touch their nose
with the tip of their index finger,
then touch your fingertip
• 2. Position your finger so that the
patient has to fully outstretch their
arm to reach it
• 3. Ask them to continue to do this
finger to nose motion as fast as they
are able to
• 4. Repeat the test using the patient’s
other hand
• lower limb
• Heel-to-shin test
• With the patient lying supine, ask him to place his heel on his opposite knee, and
then slide his heel up and down the shin between knee and ankle .
• THE SENSORY SYSTEM
• Proprioception (joint position sense) and vibration are in the posterior (dorsal)
columns of the spinal cord.
• Pain and temperature sensation are in the spinothalamic tract of the spinal
cord

•For testing cutaneous sensation of limbs

apply stimuli at points called dermatomes .
A dermatome is the band of skin
innervated by the sensory root of a single
• Light touch
• While the patient looks away or closes his eyes, use a wisp of cotton wool and ask the
patient to say yes to each touch.
• Time the stimuli irregularly and make a dabbing rather than a stroking or
tickling stimulus.
• Assess each of the dermatomes of the upper / lower limbs
• Compare each side for symmetry

• Superficial pain (Pinprick sensation )

• Repeat the previous assessment steps, but this time using the sharp end of a
neuro-tip .
• Explain and demonstrate that the ability to feel a sharp pinprick is being tested.

• Temperature
• Touch the patient with a cold metallic object, e.g. tuning fork, and ask if it feels
• Vibration
• Place a vibrating tuning fork over the sternum.
• Ask the patient, ‘Do you feel it buzzing?’
• Ask the patient to close their eyes
• For the upper limb. Start at the distal interphalangeal joint of the forefinger
( index finger ) and If vibration sensation is impaired, continue to assess the bony
prominence of more proximal joints (interphalangeal joint of
thumb →carpometacarpal joint of thumb → elbow → shoulder)
• For the lower limb . Place it on the tip of the great toe
If sensation is impaired, place the fork on the interphalangeal joint and progress
proximally, to the medial malleolus, tibial tuberosity and anterior iliac spine,
depending upon the response.
• Joint position sense (Proprioception )
• With the patient’s eyes open, demonstrate the procedure.
• Hold the distal phalanx of the patient’s great toe / middle finger at the sides.
• Tell the patient you are going to move his toe / middle finger up or down,
demonstrating as you do so .
• Ask the patient to close his eyes and to identify the direction of small movements
in random order.
•Test both great toes (or middle fingers). If impaired, move to
more proximal joints in each limb. (big toe > ankle > knee > hip)
(finger > wrist > elbow > shoulder)
• Discriminative Sensations.
• Stereognosis (identify an object) and graphaesthesia ( recognize writing on
the skin)
• Ask the patient to close his eyes.
• Place a familiar object, e.g. coin or key, in his hand and ask him to identify it
(stereognosis).
• Use the blunt end of a pencil or orange stick , draw a large number in the patient’s
palm. Ask the patient to identify the number (graphaesthesia).
• Sensory inattention
• Ask the patient to close his eyes.
• Touch his arms/legs in turn and ask which side has been touched.
• Now touch both sides simultaneously and ask whether the left, right or both sides were
touched.
• Two-point discrimination
• use reshaped paperclip to do the testing . alternate randomly between touching the
patient with one point or with two points on the area being tested (e.g. finger, arm, leg,
toe). The patient is asked to report whether one or two points was felt.
Reference: Macleod’s
Lecture note
Dr Zaid alhelo