Neurological
Examination
Motor System
Prof. Dr. Hülya Apaydın
Nöroloji AB Dalı
Cortically Originated Movement
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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
Motor Function
Nervous System Examination
Terminology Used to Describe
Muscle Weakness
Terminology
-plegia (suffix)
-paresis (suffix)
Definition
Paralysis of a muscle or a limb( 0/5)
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
Grading Motor Strength Grade
0/5 No muscle movement
Visible muscle movement, but
1/5
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
Some Diagnostically Relevant Function of the Major Regions
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Region
Brain (hemispheric
cortex )
Brain (deep cerebral
hemisphere )
Brainstem
Cerebellum
Spinal cord
Nerve root
Peripheral nerve
(or cranial nerve)
Neuromuscular
junction
Muscle
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Some major function of the region
Thought, language, memory, visual perception of contralateral
space,
contralateral motor and sensory function
Contralateral motor and sensory function
Eye movements, motor and sensory function of face and body,
alertness, sensation of nausea, coordination of extremities,
balance
Coordination of extremities, balance
Motor and sensory function of the body and extremities,
bowl and bladder control
Motor and sensory function in territory of nerve root
Motor and sensory function in territory of nerve or cranial nerve
Motor function of extremities, eye movements, swallowing,
breathing
Motor function
Characteristic Symtomps and Signs of
Neurological Disease at Different Major
Locations
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General Location
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Characteristic Symptoms and Signs Suggestive of
Localization to This Region
Brain (hemispheric
cortex)
Cognitive dysfunction, speech and language dysfunction,
hemiparesis, hemisensory loss, visual field deficits,
headache, upper motor neuron signs
Brain (deep hemisphere)
Hemiparesis, hemisensory loss, headache, upper motor neuron
signs
Brainstem
Cerebellum
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
Ataxia of gait or extremities
Dysarthria, nausea, vomitting, vertigo Headache
Characteristic Symtomps and Signs of Neurological
Disease at Different Major Locations (continue)
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General Location
Spinal cord
Nerve root
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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
Peripheral nerve
Distal paresthesias, sensory loss, or weakness
Diminish distal reflexes (distal lower motor neuron signs)
Neuromuscular
junction
Waxing and waning weakness, dysarthria, dysphagia, ptosis,
diplopia
Muscle
Weakness (usually proximal)
Common Neurological Symptoms
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Headache
Visual Disorder
Loss of Consciousness
Speech Disorder
Motor Disorder
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Inco-ordination
Weakness
Involuntary movement
Sensory Disorder
Sphincter Disorder
Lower Cranial Nerve Disorder
Mental Disorder
Motor
Observation
•Involuntary Movements
• Fasciculation
• Myotonia
• Cramp
• Tremor
• Chorea
• Athetosis
• Ballismus
• Myoclonus
• Tetanus
Fasciculation
Myotonia
•Muscle Symmetry
•Left to Right
•Proximal vs. Distal
•Atrophy
•Pay particular attention to the
hands, shoulders, and thighs, hip.
•Gait
Muscle Tone
1. Ask the patient to relax.
2. Flex and extend the
patient's fingers, wrist,
and elbow.
3. Flex and extend patient's ankle and knee.
4. There is normally a small, continuous
resistance to passive movement.
1. Observe for decreased (flaccid) or
increased (rigid/spastic) tone.
Muscle tone
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 5
"out of five"
Grading Motor Strength Grade
0/5
No muscle movement
Visible muscle movement, but no
1/5
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
Flexion at the elbow
Extension at the elbow
Extension at the wrist
Squeeze two of your
fingers "grip"
Finger abduction
Opposition of the thumb
C5, C6,
biceps
C6, C7, C8,
triceps
C6,C7, C8,
radial n
C7, C8,T1
C8, T1,
ulnar nerve
C8,T1,
median n
Flexion at the hip
Adduction at the hips
Abduction at the hips
Extension at the hips
L2, L3, L4,
iliopsoas
L2, L3, L4,
adductors
L4, L5, S1,
gluteus
medius and
minimus
S1, gluteus
maximus
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
Pronator Drift
Ask the
(drift into pronation)
patient to
stand for 2030 seconds
with both arms
straight
forward, palms
Instruct the patient to up, and eyes
keep the arms still while closed.
you tap them briskly
downward
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
Tendon Reflex Grading Scale
Reflexes should be graded on a 0 to 4 "plus" scale:
0
Absent
1+ or +
Hypoactive
2+ or ++
"Normal"
3+ or +++
Hyperactive
without clonus
Hyperactive with
clonus
4+ or ++++
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.
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.
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
Knee reflex (L2,3,4)
1. Have the patient sit or
lie down with the knee
flexed.
2. 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.
http://meded.ucsd.edu/
clinicalmed/neuro3.htm
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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.
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.
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.
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
Paraplegia
Neuropathic
GOWER’S SIGN
Cerebellar exam
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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.
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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.
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Cerebellar exam
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Rapid Alternating Finger Movements:
Ask the patient to touch the tips of each finger to
the thumb of the same hand.
 Test both hands.
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Interpretation: The movement should be fluid
and accurate. Inability to do this, known as
dysdiadokinesia, may be indicative of cerebellar
disease.
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Cerebellar exam
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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.
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Interpretation: The movement should be
performed with speed and accuracy. Inability to
do this, known as dysdiadokinesia, may be
indicative of cerebellar disease.
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Cerebellar exam
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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.
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Intepretation: The movement should trace a straight
line along the top of the shin and be done with
reasonable speed.
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Cerebellar exam
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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.
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Cerebellar disease
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