MOTOR EXAM: NORMAL EXAM

Upper extremities – Inspection and Palpation

The muscles are inspected for bulk and fasciculations and, when indicated, palpated for tenderness, consistency and contractures.

Tone - Upper extremity

Muscle tone is assessed by putting selected muscle groups through passive range of motion. The most commonly used maneuvers for the upper extremities are flexion and extension at the elbow and wrist.

Strength testing - Upper extremity

Muscle strength is tested from the proximal to the distal part of the extremity so that all segmental levels for the extremity are tested (for the upper extremity that is C5 to T1 – see table). Muscle power is graded on a scale of 0-5 (see table)

Strength Testing

C5 – Shoulder extension
C6 – Arm flexion
C7 – Arm extension
C8 – Wrist extensors
T1 – Hand grasp

Muscle Strength Grading

0 – No contraction
1 – Slight contraction, no movement
2 – Full range of motion without gravity
3 – Full range of motion with gravity
4 – Full range of motion , some resistance
5 – Full range of motion, full resistance

Stretch or Deep Tendon Reflexes - Upper extremity

A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's are listed below.

Levels for DTR's

Biceps – C5-6
Brachioradialis – C5-6
Triceps – C7
Finger Flexors – C8

Grading DTR's

0 – Absent
1 – Decreased but present
2 – Normal
3 – Brisk and excessive
4 – With clonus

Testing for pronator drift - Upper extremity

The patient extends their arms in front of them with the palms up and eyes closed. The examiner watches for any pronation and downward drift of either arm. If there is pronator drift this indicates corticospinal tract disease.

Lower extremities – Inspection and Palpation

The muscles are inspected for bulk and fasciculations and, when indicated, palpated for tenderness, consistency and contractures.

Tone - Lower extremity

Muscle tone is assessed by putting selected muscle groups through passive range of motion. The most commonly used maneuvers for the lower extremities are flexion and extension at the knee and ankle.

Strength testing - Lower extremity

Muscle strength is tested from the proximal to the distal part of the extremity so that all segmental levels for the extremity are tested (for the lower extremity that is L2 to S1 – see table). Muscle power is graded on a scale of 0-5 (see table)

Strength Testing

L2 – Hip flexion
L3 – Knee extension
L4 – Knee flexion
L5 – Ankle dorsiflexon
S1 – Ankle plantar flexion

Muscle Strength Grading

0 – No contraction
1 – Slight contraction, no movement
2 – Full range of motion without gravity
3 – Full range of motion with gravity
4 – Full range of motion, some resistance
5 – Full range of motion, full resistance

Stretch or Deep Tendon Reflexes - Lower extremity

A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's are listed below.

Levels for DTR's

Patellar or Knee – L2-4
Ankle – S1-2

Grading DTR's

0 – Absent
1 – Decreased but present
2 – Normal
3 – Brisk and excessive
4 – With clonus

Plantar Reflex - Lower extremity

The plantar reflex is a superficial reflex obtained by stroking the skin on the lateral edge of the sole of the foot, starting at the heel advancing to the ball of the foot then continuing medially to the base of the great toe. The normal response is flexion of all the toes. The abnormal response is called a Babinski sign and consists of extension of the great toe and fanning of the rest of the toes.

Pathological reflexes - frontal release signs - snout, root, palmomental

These patterned behavior reflexes appear when there is damage to the frontal lobes, which inhibits these primitive reflexes. In the normal person these reflexes are absent. 
Pressing a tongue blade on the lips tests for the snout reflex. The abnormal response is a pouting of the lips. 
The root reflex is tested for by gently stroking the lateral upper lip. The abnormal response is movement of the mouth towards the stimuli. 
Stroking the palm of the hand while watching for contraction of the ipsilateral mentalis muscle of the lower lip tests for the palmomental reflex.

Strength testing using squat & rise, heel & toe

The strength of the powerful muscles of the lower extremities is often best assessed by using the patient's own weight. Having the patient squat and rise tests the pelvic girdle and upper leg muscles while heel and toe walking tests the muscles of the foreleg.

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