THE NEUROLOGIC EXAMINATION

MOTOR SYSTEM EXAMINATION

Motor System Examination, including Cerebellar tests

• Inspection: Body position

Involuntary movements
Muscle bulk
• Muscle Tone
• Manual Motor Testing
• Coordination and Gait
Examination of the motor system
1. Inspection and Palpation
• Tremors: Parkinsonian / Metabolic / Cerebellar / Essential
Rubral / Physiologic tremor, Tremor of Hepatic
encephalopathy
• Dystonia
• Involuntary movements: Chorea, Tardive dyskenisia,
Athetosis, Pseudoathetosis, Choreoathetosis, Ballism
• Clonus / Myoclonus
• Spasm: muscle cramps, oculogyric crisis, hemifacial
cramps, palatal myoclonus or nystagmus,
blepharospasm, hiccup
• Seizures
2. Muscle Symmetry
Left to Right
Proximal vs. Distal
Atrophy (particular attention to the hands, shoulders, and thighs)
3. Gait
Examination of the motor system

Muscle Tone
Ask the patient to relax.
Flex and extend the patient's fingers, wrist, and elbow.
Flex and extend patient's ankle and knee.
There is normally a small, continuous resistance to passive
movement.
Observe for decreased (flaccid) or increased (rigid/spastic)
tone.
Testing of motor and sensory function requires a basic understanding of
normal anatomy and physiology.

In brief:
• Voluntary movement begins with an impulse generated by cell bodies
located in the brain.
• Signals travel from these cells down their respective axons, forming the
Corticospinal (a.k.a. Pyramidal) tract.
• At the level of the brain stem, this motor pathway crosses over to the
opposite side of the body and continue downward on that side of the
spinal cord. The nerves which comprise this motor pathway are
collectively referred to as Upper Motor Neurons (UMNs).
• At a specific point in the spinal cord the axon synapses with a 2nd
nerve, referred to as a Lower Motor Neuron (LMN). The precise
location of the synapse depends upon where the lower motor neuron is
destined to travel. If, for example, the LMN terminates in the hand, the
synapse occurs in the cervical spine (i.e. neck area). However, if it’s
headed for the foot, the synapse occurs in the lumbar spine (i.e. lower
back).
• The UMNs are part of the Central Nervous System (CNS), which is
composed of neurons whose cell bodies are located in the brain or spinal
cord.
• The LMNs are part of the Peripheral Nervous System (PNS), made
up of motor and sensory neurons with cell bodies located outside of the
brain and spinal cord. The axons of the PNS travel to and from the
periphery, connecting the organs of action (e.g. muscles, sensory
receptors) with the CNS.
• Nerves which carry impulses away from the CNS are referred to
Efferents (i.e. motor) while those that bring signals back are called
Afferents (i.e. sensory).
• Axons that exit and enter the spine at any given level generally
connect to the same distal anatomic area. These bundles of axons,
referred to as spinal nerve roots, contain both afferent and efferent
nerves. The roots exit/enter the spinal cord through neuroforamina in the
spine, paired openings that allow for their passage out of the bony
protection provided by the vertebral column.
 As the efferent neurons travels peripherally, components from
different roots commingle and branch, following a highly programmed
pattern. Ultimately, contributions from several roots may combine to
form a named peripheral nerve, which then follows a precise anatomic
route on its way to innervating a specific muscle.
The Radial Nerve, for example, travels around the Humerus
contains contributions from Cervical Nerve Roots 6, 7 and 8 and
innervates muscles that extend the wrist and supinate the forearm.
It may help to think of a nerve root as an electrical cable composed
of many different colored wires, each wire representing an axon. As
the cable moves away from the spinal cord, wires split off and head to
different destinations. Prior to reaching their targets, they combine with
wires originating from other cables. The group of wires that ultimately
ends at a target muscle group may therefore have contributions from
several different roots.
Signs of Upper Motor Neuron (UMN) and Lower
Motor Neuron (LMN) Lesions

SIGN UNM Lesion LMN Lesion

Weakness Yes Yes

Atrophy No * Yes

Fasciculation No Yes

Reflexes Increased Decreased

Tone Increased Decreased

* Mild atrophy may develop due to disuse

 Motor Testing
• The muscle is the unit of action that causes movement.
Normal motor function depends on intact upper and
lower motor neurons, sensory pathways and input from a
number of other neurological systems. Disorders of
movement can be caused by problems at any point
within this interconnected system.

• Muscle Bulk and Appearance:

This assessment is somewhat subjective and quite
dependent on the age, sex and the activity/fitness level
of the individual. A frail elderly person, for example, will
have less muscle bulk then a 25 year old body builder.
With experience, you will get a sense of the normal
range for given age groups, factoring in their particular
activity levels and overall states of health.
 Motor Testing
• Things to look for:
Using your eyes and hands, carefully examine the major
muscle groups of the upper and lower extremities. Palpation of the
muscles will give you a sense of underlying mass. The largest and
most powerful groups are those of the quadriceps and hamstrings
of the upper leg (i.e. front and back of the thighs). The patient
should be in a gown so that the areas of interest are exposed.

• Muscle groups should appear symmetrically developed when

compared with their counterparts on the other side of the body.
They should also be appropriately developed, after making
allowances for the patient’s age, sex, and activity level.
Muscle Assymetry
While both legs have well developed musculature,
the left has greater bulk.
Motor Testing
• There should be no muscle movement when the limb is at rest.
Rare disorders (e.g. Amyotrophic Lateral Sclerosis) result in
death of the lower motor neuron and subsequent denervation of
the muscle. This causes twitching of the fibers known as
fasciculations, which can be seen on gross inspection of affected
muscles.

• Tremors are a specific type of continuous, involuntary muscle

activity that results in limb movement. Parkinson’s Disease (PD),
for example, can cause a very characteristic resting tremor of the
hand (the head and other body parts can also be affected) that
diminishes when the patient voluntarily moves the affected limb.
Benign Essential Tremor, on the other hand, persists throughout
movement and is not associated with any other neurological
findings, easily distinguishing it from PD.
Motor Testing

• The major muscle groups to be palpated include:

biceps, triceps, deltoids, quadriceps and hamstrings.

• Palpation should not elicit pain. Interestingly, myositis

(a rare condition characterized by idiopathic muscle
inflammation) causes the patient to experience weakness
but not pain.
 Motor Testing
• If there is asymmetry, note if it follows a particular pattern.
Remember that some allowance must be made for handedness
(i.e. right v left hand dominance).
• Does the asymmetry follow a particular nerve distribution,
suggesting a peripheral motor neuron injury? For example,
muscles which lose their LMN innervation become very atrophic.
• Is the bulk in the upper and lower extremities similar? Spinal
cord transection at the Thoracic level will cause upper extremity
muscle bulk to be normal or even increased due to increased
dependence on arms for activity, mobility, etc. However, the
muscles of the lower extremity will atrophy due to loss of
innervation and subsequent disuse.
• Is there another process (suggested by history or other
aspects of the exam) that has resulted in limited movement of a
particular limb? For example, a broken leg that has recently
been liberated from a cast will appear markedly atrophic.
Diffuse Muscle Wasting:
Note loss muscle bulk in left hand due to peripheral denervation.
In particular, compare left and right thenar eminences.
MOTOR TESTING: Tone
When a muscle group is relaxed, the examiner should be able to
easily manipulate the joint through its normal range of motion. This
movement should feel fluid. A number of disease states may alter this
sensation. For the screening examination, it is reasonable to limit this
assessment to only the major joints, including: wrist, elbow, shoulder, hips
and knees.

Technique:
• Ask the patient to relax the joint that is to be tested.
• Carefully move the limb through its normal range of motion, being careful
not to maneuver it in any way that is uncomfortable or generates pain. Be
aware that many patients, particularly the elderly, often have other medical
conditions that limit joint movement. Degenerative joint disease of the
knee, for example, might cause limited range of motion, though tone
should still be normal.
• If the patient has recently injured the area or are in pain, do not perform
this aspect of the exam.
 MOTOR TESTING: Tone
Things to look for:
• Normal muscle generates some resistance to movement when
a limb is moved passively by an examiner.
• Increased tone (hypertonicity) results from muscle contraction.
At the extreme end is spasticity, which occurs when the upper
motor neuron no longer functions. In this setting, the affected limb
is held in a flexed position and the examiner may be unable to
move the joint. This is seen most commonly following a stroke,
which results in the death of the upper motor neuron cell body in
the brain.
• Flaccidness is the complete absence of tone. This occurs when
the lower motor neuron is cut off from the muscles that it normally
innervates.
 MOTOR TESTING: Tone

Disorders that do not directly affect the muscles, upper or lower

motor neurons can still alter tone.
Perhaps the most common of these is Parkinson’s Disease (PD).
This is a disorder of the Extra Pyramidal System (EPS). The
EPS normally contributes to initiation and smoothness of
movement. PD causes increased tone, generating a ratchet-like
sensation (known as cog wheeling) when the affected limbs are
passively moved by the examiner.
MOTOR TESTING: Strength

As with muscle bulk, strength testing must take into account the
age, sex and fitness level of the patient. For example, a frail,
elderly, bed bound patient may have muscle weakness due to
severe deconditioning and not to intrinsic neurological disease.
Interpretation must also consider the expected strength of the
muscle group being tested. The quadriceps group, for example,
should be much more powerful then the Biceps.
Proximal weakness Suggestive of myopathy
Distal Weakness Suggestive of peripheral neuropathy
Pyramidal Weakness Suggestive of UMN dysfunction
Grading of Muscle Strength

Grade Description

0/5 No muscle movement

1/5 Slight contractility but no joint motion

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
MOTOR TESTING: Strength

• Specifics of Strength Testing - Major Muscle Groups: In the

screening examination, it is reasonable to check only the major
muscles/muscle groups. More detailed testing can be performed
in the setting of discrete/unexplained weakness. The names of
the major muscles/muscle groups along with the spinal roots and
peripheral nerves that provide their innervation are provided
below. Nerve roots providing the greatest contribution are printed
in bold. More extensive descriptions of individual muscles and
their functions, along with their precise innervations can be found
in a Neurology reference text.
• Intrinsic muscles of the hand (C 8, T 1): Ask the patient to spread
their fingers apart against resistance (abduction). Then squeeze
them together, with your fingers placed in between each of their
digits (adduction). Test each hand separately. The muscles which
control adduction and abduction of the fingers are called the
Interossei, innervated by the Ulnar Nerve.
Intrinsic muscles of the hand (C 8, T 1)
• Ask the patient to spread their fingers apart against resistance
• Squeeze them together, with your fingers placed in between each of
their digits (adduction). Test each hand separately.
The muscles which control adduction and abduction of the fingers are
called the Interossei, innervated by the Ulnar Nerve.
Flexors of the fingers (C 7, 8, T1)
• Ask the patient to make a fist, squeezing their hand around two of your
fingers. If the grip is normal, you will not be able to pull your fingers out.
Test each hand separately.
The Flexor Digitorum Profundus controls finger flexion and is innervated
by the Median (radial ½) and Ulnar (medial ½) Nerves.
Wrist flexion (C 7, 8, T 1)
• Have the patient try to flex their wrist as you provide resistance. Test
each hand separately.
The muscle groups which control flexion are innervated by the Median
and Ulnar Nerves.
Wrist extension (C 6, 7, 8)
• Have the patient try to extend their wrist as you provide resistance.
The Extensor Radialis muscles control extension and are innervated by the Radial
Nerve. Damage to the radial nerve results in wrist drop (loss of ability to extend
the hand at the wrist). The nerve can be compressed against the humerus for a
prolonged period of time when an intoxicated person loses consciousness with
the inside aspect of the upper arm resting against a solid object (known as a
“Saturday Night Palsy”).
Elbow Flexion (C 5, 6)
• Have the patient bend their elbow to ninety degrees while keeping their
palm directed upwards. Then direct them to flex their forearm while you
provide resistance.
The main flexor (and supinator) of the forearm is the Brachialis Muscle
(along with the Biceps Muscle). These muscles are innervated by the
Musculocutaneous Nerve
Elbow Extension (C 7, 8)
Have the patient extend their elbow against resistance while the arm is
held out (abducted at the shoulder) from the body at ninety degrees.
The main extensor of the forearm is the triceps muscle. The Triceps is
innervated by the Radial Nerve.
Shoulder Adduction (C5 thru T1)
• Have the patient flex at the elbow while the arm is held out from the
body at forty-five degrees. Then provide resistance as they try to further
adduct at the shoulder.
The main muscle of adduction is the Pectoralis Major, though the
Latissiumus and others contribute as well.
Shoulder Abduction (C 5, 6)
• Have the patient flex at the elbow while the arms is held out from the
body at forty-five degress. Then provide resistance as they try to further
abduct at the shoulder.
The deltoid muscle, innervated by the axillary nerve, is the main muscle
of abduction.
Hip Flexion (L 2, 3, 4)
• With the patient seated, place your hand on top of one thigh and
instruct the patient to lift the leg up from the table.
The main hip flexor is the Iliopsoas muscle, innervated by the femoral
nerve.
Hip Extension (L5, S1)
• With the patient lying prone, direct the patient to lift their leg off the
table against resistance.
The main hip extensor is the gluteus maximus, innervated by inferior
gluteal nerve.
Hip Abduction (L 4, 5, S1)
• Place your hands on the outside of either thigh and direct the patient
to separate their legs against resistance.
This movement is mediated by a number of muscles.
Hip Adduction (L2, 3, 4)
• Place your hands on the inner aspects of the thighs.
A number of muscles are responsible for adduction. They are
innervated by the obturator nerve
Knee Extension (L2, 3, 4)
• Have the seated patient steadily press their lower extremity into your
hand against resistance.
Extension is mediated by the quadriceps muscle group, which is
innervated by the femoral nerve.
Knee flexion (L5, S1, 2)
• Have the patient rest prone. Then have them pull their heel up and
off the table against resistance.
Flexion is mediated by the hamstring muscle group, via branches of the
sciatic nerve.
Ankle Dorsiflexion (L4, 5)
• Direct the patient to pull their toes upwards while you provide
resistance with your hand.
The muscles which mediate dorsiflexion are innervated by the deep
peroneal nerve. The peroneal nerve is susceptible to injury at the point
where it crosses the head of the fibula (laterally, below the knee). If
injured, the patient develops “Foot Drop,” an inability to dorsiflex the
foot.
Ankle Plantar Flexion (S 1, S 2)
• Have the patient “step on the gas” while you provide resistance.
The gastrocnemius and soleus, the muscles which mediate this
movement, are innervated by a branch of the sciatic nerve. Plantar
flexion and dorsiflexion can also be assessed by asking the patient to
walk on their toes (plantar flexion) and heels (dorsiflexion).
It is generally quite helpful to directly compare right vs left
sided strength, as they should more or less be equivalent
(taking into account the handedness of the patient). If there
is weakness, try to identify a pattern, which might provide a
clue as to the etiology of the observed decrease in strength.
In particular, make note of differences between:
• Right vs Left
• Proximal muscles vs distal
• Upper extremities vs lower

Or is the weakness generalized, suggestive of a systemic

neurological disorder or global deconditioning
Special Testing for subtle weakness:
Subtle weakness can be hard to detect. Pay attention to
how the patient walks, uses and holds their arms and
hands as they enter the room, get up and down from a
seated position, move onto the examination table, etc.

Pronator drift is a test for slight weakness of the upper

extremities.
• Ask the patient to stand for 20-30 seconds with both
arms straight forward, palms up, and eyes closed.
• Instruct the patient to keep the arms still while you tap
them briskly downward.
• The patient will not be able to maintain extension and
supination (and "drift into pronation) with upper motor
neuron disease.
Common peripheral nerves, territories of innervation, and clinical
correlates.
Peripheral Nerve Sensory Motor Innervation Contributing Spinal Clinical
Innervation Nerve Roots

Radial Nerve Back of thumb, Wrist extension and C6, 7, 8 At risk for compression at
index, middle, and ½ abduction of thumb humerus, known as
"Saturday Night Palsy“
ring finger; back of in palmer plane
forearm

Ulnar Nerve Palmar and dorsal Abduction of fingers C7, 8 and T1 At risk for injury with
aspects of pinky and (intrinsic muscles of elbow fracture.
½ of ring finger hand) Can get transient
symptoms when inside of
elbow is struck ("funny
bone" distribution)

Median Nerve Palmar aspect of the Abduction of thumb C8, T1 Compression at carpal
thumb, index, middle perpendicular to tunnel causes carpal
tunnel syndrome
and ½ ring finger; palm (thenar
palm below these muscles).
fingers.
.Lateral aspect thigh L1, 2 Can become compressed
in obese patients, causing
Lateral Cutaneous numbness over its
Nerve of Thigh distribution

Peroneal Lateral leg, top of Dorsiflexion of foot L4, 5; S1 Can be injured with
foot (tibialis anterior proximal fibula fracture,
leading to foot drop
muscle) (inability to dorsiflex foot)
Neurologic examination
GAIT & STATION
 GAIT TESTING

• Ability to stand and walk normally is dependent on

input from several systems, including: visual,
vestibular, cerebellar, motor, and sensory.
• The precise cause(s) of the dysfunction can be
determined by identifying which aspect of gait is
abnormal and incorporating this information with that
obtained during the rest of the exam. Difficulty getting
out a chair and initiating movement, for example,
would be consistent with Parkinson’s Disease. On the
other hand, lack of balance and a wide based gait
would suggest a cerebellar disorder.
Ask the patient to:

Walk across the room, turn and come back

Walk heel-to-toe in a straight line
Walk on their toes in a straight line
Walk on their heels in a straight line
Hop in place on each foot
Do a shallow knee bend
Rise from a sitting position
 TESTING OF STATION
(EQUILIBRATORY COORDINATION)

• Cerebellar ataxia is not ameliorated by visual orientation

• Have the patient stand in one place. This is a test of
balance, incorporating input from the visual, cerebellar,
proprioceptive, and vestibular systems. If they are able
to do this, have them close their eyes, removing visual
input. This is referred to as the Romberg test. Loss of
balance suggests impaired proprioception.
• In disease of the cerebellum:
- lateral lobe, falling is toward the affected side
- frontal lobe, falling is to the opposite side
- midline or vermis, falling indiscriminately
• Ask the patient to stand from a chair, walk across the
room, turn, and come back towards you. Pay particular
attention to:
– Difficulty getting up from a chair: Can the patient easily arise
from a sitting position? Problems with this activity might suggest
proximal muscle weakness, a balance problem, or difficulty
initiating movements.
– Balance: Do they veer off to one side or the other as might occur
with cerebellar dysfunction? Disorders affecting the left
cerebellar hemisphere (as might occur with a stroke or tumor)
will cause patient’s to fall to the left. Right sided lesions will
cause the patient to fall to the right. Diffuse disease affecting
both cerebellar hemispheres will cause a generalized loss of
balance.
– Rate of walking: Do they start off slow and then accelerate,
perhaps losing control of their balance or speed (e.g. as might
occur with Parkinson’s Disease)? Are they simply slow moving
secondary to pain/limited range of motion in their joints, as might
occur with degenerative joint disease? etc.
– Attitude of Arms and Legs: How do they hold their arms and
legs? Is there loss of movement and evidence of contractures
(e.g. as might occur after a stroke)?
• Heel to Toe Walking: Ask the patient to walk in a
straight line, putting the heel of one foot directly
in front of the toe of the other. This is referred to
as tandem gait and is a test of balance. Realize
that this may be difficult for older patients (due to
the frequent coexistence of other medical
conditions) even in the absence of neurological
disease.
Normal posture, step size, Tandem Walking
and arm swing
Hemiplegic Gait Parkinsonian Gait
Steppage Gait Retropulsion
CEREBELLAR TESTING

• The cerebellum fine tunes motor activity and assists with

balance. Dysfunction results in a loss of coordination and
problems with gait. The left cerebellar hemisphere
controls the left side of the body and vice versa.
• Specifics of Testing: There are several ways of testing
cerebellar function. For the screening exam, using one
modality will suffice. If an abnormality is suspected or
identified, multiple tests should be done to determine
whether the finding is durable. That is, if the abnormality
on one test is truly due to cerebellar dysfunction, other
tests should identify the same problem. Gait testing, an
important part of the cerebellar exam.
CEREBELLAR TESTING

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.
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.

Rapid Alternating Finger Movements:

– Ask the patient to touch the tips of each finger to the thumb of the same hand.
– Test both hands.
Interpretation: The movement should be fluid and accurate. Inability to
do this, known as dysdiadokinesia, may be indicative of cerebellar
disease.
Evaluation of cerebellar function.
While the examiner holds his finger at arm's length from the
patient, the patient touches her nose and then touches the
examiner's finger. After several sequences, the patient is asked to
repeat the exercise with her eyes shut. A patient with a cerebellar
disorder tends to overshoot the target.
CEREBELLAR TESTING
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.
Interpretation: The movement should be performed with speed
and accuracy. Inability to do this, known as dysdiadokinesia, may
be indicative of cerebellar disease.

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.
Interpretation: The movement should trace a straight line along
the top of the shin and be done with reasonable speed.
Rapid Alternating Movements
Heal Shin Test
The Romberg test. Have the patient stand still
with heels and toes together. Ask the patient to
close her eyes and balance herself. If the patient loses
her balance, the test is positive.
THE END