Neurological Motor Exam

Front 1

What elements are involved in the motor exam?

Back 1

Strength, muscle bulk, reflexes, muscle tone, coordination, resting posture, gait

Front 2

What is the scale by which strength is measured and what do each of the numbers stand for?

Back 2

Strength is measured on a 0-5 scale.
5 = normal
4 = slight weakness
3 = just strong enough to move against gravity but not additional resistance
2 = can move, but not against gravity
1 = can see/palpate movement of muscle, but no actual motion of body
0 = no motion at all
Some people add plus and/or minus signs in.

Front 3

What is an important aspect when assessing strength during a neuro exam?

Back 3

Trying to assess effort. Collapsing weakness or breakaway weakness is different than not trying weakness. Is it physiological? Or is this person trying to get workman's comp.

Front 4

What nerve roots are involved with Shoulder abduction?

Back 4

C5-6

Front 5

What nerve roots are involved with shoulder external rotation?

Back 5

C5

Front 6

What nerve roots are involved with elbow flexion?

Back 6

C5-C6

Front 7

What nerve roots are involved with elbow extension?

Back 7

C7

Front 8

What nerve roots are involved with wrist flexion?

Back 8

C7-C8

Front 9

What nerve roots are involved with wrist extension?

Back 9

C7

Front 10

What nerve roots are involved with intrinsic hand muscles?

Back 10

C8-T1

Front 11

What nerve roots are involved with hip flexion?

Back 11

L2-3

Front 12

What nerve roots are involved with hip extension?

Back 12

L4-5

Front 13

What nerve roots are involved with knee flexion?

Back 13

L5-S1

Front 14

What nerve roots are involved with knee extension?

Back 14

L3-4

Front 15

What nerve roots are involved with ankle plantar flexion?

Back 15

S1-2

Front 16

Whatever nerve roots are involved with ankle dorsiflexion?

Back 16

L4-5

Front 17

What nerve roots are involved with ankle inversion and eversion?

Back 17

L5-S1

Front 18

What is the best way to test limb strength?

Back 18

Test them in a physiological way... maybe with pronator drift, toe walk/ heel walk, hop or climb a step, arise from chair, circle rotation test, closing of hand, rapid alternating movements (RAM)

Front 19

What are the 4 types of weakness to the muscles?

Back 19

1) Upper motor neuron- damage to central descending motor pathways (think CORTICOSPINAL tract)
2) Lower motor neuron- damage to the anterior horn cell or its axon (in nerve roots and peripheral nerve)
3) Muscle disease- usually see weakness in the proximal (big) muscles
4) Disease of the neuromuscular junction- presents with muscle fatigue typically starting with muscles that work all the time such as the eye muscles.

Front 20

What are the two types of atrophy and what causes them?

Back 20

1) Disuse: this can be due to many causes such as bedrest or casting and can be reversed with exercise.
2) Neutrogenic atropy: It is severe and indicates lower motor neuron involvement (anterior horn cell or its axon).

Front 21

What is breakaway weakness a sign of?

Back 21

malingering aka functional weakness

Front 22

What are signs of functional weakness or malingering?

Back 22

Pronator drift test is different, Hoover's sign, hold weak arm over face, able to use legs sitting down but unable to stand on them, breakaway weakness

Front 23

What are the two types of reflexes and what are they helpful in?

Back 23

Reflexes are helpful in assessing the cause of muscle weakness.
1) Deep tendon (myotatic) reflexes
2) Superficial reflexes

Front 24

What do the myotactic reflexes represent and what inhibits them?

Back 24

Monosynaptic spinal reflex which are lower motor neurons with the muscle stretch afferent pathway. These pathways are under inhibitory control by descending motor pathways the cerebral cortex via pyramidal pathways aka upper motor neurons (UMN)

Front 25

How are deep tendon reflexes graded?

Back 25

It is graded on a 0-4+ scale.

1+ sluggish
2+ normal
3+ brisk
4+ sustained clonus
You must try reinforcement before you can consider the reflex to be "0"

Front 26

What's the most important observation you can make about deep tendon reflexes?

Back 26

Checking that they are symmetrical and correlate with other motor and sensory signs. Remember that there is a wide range of normal!!

Front 27

What does pathological spread of reflexes look like?

Back 27

Only the muscle whose tendon is struck normally contracts... will see "crossed adduction". Remember the video he showed.

Front 28

What is clonus?

Back 28

It is something that can occur when the myotatic reflexes are tested. The muscle contracts with manual stretching of the tendon. It is most common at the ankle but can also test at the wrist or patella. Clonus can be sustained or unsustained. Want to notice how many "beats". Sustained clonus is always abnormal.

Front 29

What nerve level are the biceps and brachioradialis reflexes at?

Back 29

C6

Front 30

What nerve level is the triceps reflex at?

Back 30

C7

Front 31

What is the nerve level of the finger flexor muscle reflexes?

Back 31

C8

Front 32

What nerve level is the knee reflex?

Back 32

L4 (with a little L3)

Front 33

What nerve level is the ankle jerk reflex at?

Back 33

S1

Front 34

What kind of reflex is the response to scratching the skin? What do the different responses to it mean?

Back 34

It is a superficial reflex.
A plantar response is the normal response to lateral plantar stimulation (so downgoing toe). When trying to elicit the response you scrape along the lateral side of the foot and across the ball of the the foot to the base of the great toe. If you don't get a response, try it again faster and deeper. Stay lateral and take care to avoid plantar grasp reflex. No response suggests damage to descending motor tracts or sensory deficit.

Front 35

What is the abdominal reflex?

Back 35

It is a superficial reflex where the muscle in the quadrant of the abdomen you scratch contracts.

Front 36

What is the Cremaster reflex?

Back 36

It is rapid, brief elevation of the testicle on the side of the scratch of the medial thigh. It tests nerve levels L1-L2.

Front 37

What is the most important consideration with superficial reflexes?

Back 37

symmetry! Absence of symmetry or of a reflex suggests upper motor neuron damage.

Front 38

What is the Babinski sign?

Back 38

It is dorsiflexion of the toe in response to scratching the bottom of the foot which normally elicits the plantar response. It indicates upper motor neuron damage( somewhere along the corticospinal track pyramidal/UMN) though it is normal in babies.

Front 39

Besides the Babinski sign, what are some other pathological reflexes?

Back 39

Tromner's: volar surface of the fingers are tapped.
Hoffmann's: You flick the fingers and look for flexion of the thumb.

Front 40

What if a patient is too ticklish and a proper babinski test can not be performed?

Back 40

There are alternative tests you can do!
Oppenheim maneuver: painful rub along the anterior tibia with thumb and forefinger can elicit an upgoing plantar reflex.
Chaddock maneuver: Firm pressure along the lateral foot can elicit an upgoing plantar reflex
Gonda's maneuver: extensor plantar response by flicking the little toe or 4th toe
Schafer maneuver: pinching the Achilles tendon can elicit it also.

Front 41

What are the regressive/primitive reflexes?

Back 41

Grasp, snout, routing, palmomental, glabellar, nuchocephalic

Front 42

What does an increased jaw jerk signify?

Back 42

It is suggestive of UMN pathology above the brainstem.

Front 43

What does decreased muscle tone indicate? What might you see (symptoms)?

Back 43

Decrease in muscle tone typically is due to lower motor neuron dmage or damage to sensory fibers. Decreased muscle tone=flaccidity. Usually decreased muscle tone is associated with decreased myotatic reflexes

Front 44

What are the 3 patterns of increased muscle tone?

Back 44

1) Rigidity: constance increased tone throughout like a lead pipe = a basal ganglia disease. Usually the limb doesn't return to original position like spasticity does.
2) Spasticity: clasped knife rigidity=corticospinal tract disease. With rapid passive displacement, resistance of muscle tone increases then suddenly relaxes (clasp-knife phenomena)
3) Paratonia: Gegenhalten, an inhability to relax= this is seen with frontal lobe dysfunction.

Front 45

What is the exception to what UMN lesions cause?!

Back 45

Usually they cause spasticity, but acutely they can cause flaccidity!! Be careful in evaluating a patient to not just assume it's LMN damage if there is flaccidity acutely!

Front 46

What is the prototype neuromuscular junction disease?

Back 46

Myasthenia Gravis

Front 47

Muscular dystrophies: what is seen in regards to weakness and reflexes?

Back 47

Usually proximal weakness and anyway from normal to diminished reflexes.

Front 48

Do acquired myopathies usually affect proximal or distal muscles?

Back 48

Usually proximal.

Front 49

What causes UMN syndrome?

Back 49

Damage to the motor tracts either via the spinal cord, brainstem, internal capsule or cerebral cortex

Front 50

What causes LMN syndrome?

Back 50

Damage to motor neurons either in anterior horn of the spinal cord, nerve root, plexus, or peripheral nerves.

Front 51

What are the changes that occur with UMN damage with reflexes, tone, and muscle bulk?

Back 51

Reflexes- increased; tone- increased (spasticity) Remember acutely may be flaccidity though; Bulk: disuse atrophy

Front 52

What are the changes that occur with LMN damage with reflexes, tone, and muscle bulk?

Back 52

Reflexes: decreased; Muscle tone: decreased (flaccidity); muscle bulk: severe

Front 53

How is coordination tested?

Back 53

usually coordination is tested with rapid alternating movements or finger to nose testing. Any skilled movements can be used such as sliding your heel along your shin (as another example). Coordination testing tests strength, tone, and sensation

Front 54

How does cerebellar damage affect coordination?

Back 54

It decreases coordination without affecting other motor functions.

Front 55

What is Dysdiadochokinesis?
Then say it five times fast haha.

Back 55

Dysdiadochokinesis is the clinical term for an inability to perform rapidly alternating movements.

Front 56

What causes dysdiadochokinesia?

Back 56

Dysdiadochokinesia is often caused by multiple sclerosis in adults and cerebellar tumors in children. There may be a false impression of dysdiadochokinesia secondary to weakness in patients with Parkinson's disease (or other movement disorders) and UMN lesions. This is because they can have abnormal rapid alternating movements secondary to weakness, akinesia, or rigidity creating the false impression.

Front 57

What can you gain about the motor exam just from observation?

Back 57

Posture, frequency/speed of movement, abnormal movements at rest. You can often make a diagnosis just carefully watching the patient walk into the clinic exam room!

Front 58

What are some abnormal movements at rest?

Back 58

Tremor- resting, postural (attention), intention; chorea; athetosis; dystonia; Hemiballism; Tourette's; Myoclonus; asterixis; fasciculations

Front 59

What is chorea?

Back 59

Chorea consists of repetitive, brief, jerky, large-scale, dancelike, uncontrolled movements that start in one part of the body and move abruptly, unpredictably, and often continuously to another

Front 60

What is athetosis?

Back 60

athetosis is a continuous stream of slow, sinuous, writhing movements, generally of the hands and feet.

Front 61

What is one of the conditions associated with chorea?

Back 61

Huntington's Disease

Front 62

What types of dystonia are there?

Back 62

Torticollis, writer's camp, task specific dystonias

Front 63

What's dystonia? How many people get it? What characterizes it?

Back 63

Women develop it more than men. Less than 1% of people are affected. It is benign when it's in a single region (hand or foot for example). Occurs with a specific action. Worsens with stress fatigue, or anxiety. Quality of life impact depends on the body part affected.

Front 64

What are the common places dystonia can occur and what are the effects?

Back 64

Eyelids: rapid blinking or squinting (blepharospasm) can be so severe as to make a person functionally blind;
Neck: Cervical dystonia may cause the head to twist and turn painfully to one side or to pull forward or backwards
Jaw and tongue: Oromandibular dystonia may cause slurred speech or difficulty eating or swallowing
Hand and forearm: writer's cramp or musician's cramp causes pain during a single repetitive motion such as writing or playing an instrument

Front 65

A lot of cases of dystonia have no obvious cause... but what are some of the underlying problems that can cause it?

Back 65

TBI, stroke, brain tumor, O2 deprivation, infections such as tuberculosis or encephalitis, reactions to certain drugs, heavy metal or carbon monoxide poisoning

Front 66

What is a therapy for dystonias and how does it work?

Back 66

Botox! It blocks the release of acetylcholine at the NMJ by blocking cleavage of SNAP25 and hence binding of synaptosome to cell membrane and release

Front 67

What are the different types of tremor?

Back 67

1) Resting: usually with Parkinson's
2) Postural: usually "essential" or "familial". May be due to thyrotoxicosis, anxiety, caffeine, excessive sympathetic/ adrenal activity
3) Action (intention)- may be essential or cerebellar

Front 68

What is an essential tremor?

Back 68

It is an idiopathic tremor that is one of the most common neuro diseases with a prevalence of approximately 4% in persons aged 40 and older and considerably higher among persons in their 60s, 70s, 80s, and 90s. Many cases are inherited.

Front 69

What is myoclonus?

Back 69

Myoclonus is sudden activation of muscles which can be normal, can be due to damage to several levels of the nervous system, or can be due to encephalopathy.

Front 70

What is asterixis?

Back 70

Asterixis is a sudden, erratic loss of muscle tone. It can be due to encephalopathy/ delerium, toxic chemicals, metabolic causes, or drugs.

Front 71

What causes fasciculations?

Back 71

They can be normal or can happen with damage to lower motor neurons.

Front 72

What are the different gait disorders?

Back 72

Antalgic gait of joint pain (hip) – less time spent weight bearing on affected joint
Trendelenburg gait (unilateral weakness of hip abductors – gluts) – leaning to lesioned
side with every contralateral leg swing
Waddling gait of proximal myopathy (osteomalacia, polymyosites, etc.)
Fatiguing gait of MG
High stepping gait of foot drop or proprioceptive loss
Dragging leg of UML (stroke) – scissor gait in CP
Ataxic ‘drunken’ gait of cerebellar lesions - broad based, leaning to lesioned side
Shuffling gait of PD
Apraxic gait (small, ‘magnetic’ steps)
Normal pressure hydrocephalus - triad of gait apraxia, urinary incontinence, and
dementia (often reverible with shunt). “Magnetic gait”
Frontal lesions ("frontal apraxia")
Bizarre, non-falling, inconsistent gait of hysteria. “astasia-abasia”
Astasia refers to the inability to maintain station (stand upright) unassisted.
Abasia refers to lack of motor coordination in walking. The term literally means that the
base of gait (the lateral distance between the two feet) is inconstant or unmeasurable.
When seen in conversion disorder, the gait is bizarre and is not suggestive of a specific
organic lesion: often the patient sways wildly and nearly falls, recovering at the last moment

Front 73

What does a reeling gait suggest?

Back 73

cerebellar problems

Front 74

What does apraxic gait suggest?

Back 74

Frontal lobe disease

Front 75

What does limping suggest?

Back 75

orthopedic problem

Front 76

What is a spastic gait?

Back 76

stiff-legged, circumducting... dragging one spastic limb around the body.

Front 77

What is the parkinsonian gait?

Back 77

rigid, narrow base

Front 78

What are the various gaits of weakness?

Back 78

Steppage: lift knee high with foot-drop
Waddling: due to gluteal weakness
Lock knees with quadriceps weakness

Front 79

What is needed for station? What tests station?

Back 79

Station requires sensory, extrapyramidal, motor, cerebellar, and frontal lobe systems.
It is tested with the Romberg test (increased instability with eye closure due to sensory/ proprioceptive loss).

Front 80

What disease causes issues with station?

Back 80

Parkinsons causes delayed postural corrections and retropulsion.