According to pediatrics, how to do and what are the normal and abnormal findings for motor ,sensory, cerebellar reflexes

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Pediatric Neurological Examination: Motor, Sensory, Cerebellar & Reflexes

1. MOTOR EXAMINATION

How to Perform

Observation first: Inspect muscles in good light with the patient in a comfortable, symmetric position. Look for:

Muscle atrophy or hypertrophy
Fasciculations (fine, spontaneous twitches)
Involuntary movements at rest (tics, myoclonus, choreoathetosis, pill-rolling tremor), with posture (essential tremor), or with movement (intention tremor)

Muscle Tone

Test by passively moving a relaxed limb through flexion/extension:

Upper limb: Rapid pronation/supination of forearm; flexion/extension at wrist
Lower limb (supine): Place hands behind knees, rapidly raise them — with normal tone, heels drag along the table before lifting; with increased tone, heels lift immediately

Tone Abnormality	Description	Localization
Spasticity	Velocity-dependent increased resistance to passive stretch	Corticospinal (pyramidal) tract lesion
Rigidity	Equal resistance at all angles of motion	Extrapyramidal/basal ganglia disease
Cogwheel rigidity	Jerky interruptions during passive motion	Parkinsonism
Paratonia	Fluctuating resistance	Frontal lobe pathway disease
Flaccidity	Absent muscle tone	Lower motor neuron / peripheral nerve disorder

Muscle Strength — Grading Scale (MRC)

Grade	Description
5	Full normal power
4+	Movement against strong resistance
4	Movement against moderate resistance
4−	Movement against mild resistance
3	Movement against gravity but NOT against resistance
2	Movement with gravity eliminated
1	Flicker/trace contraction, no joint movement
0	No contraction

Screening test (upper limb): Pronator drift — ask the patient to hold both arms extended with eyes closed for ~10 seconds. Pronation of the forearm or flexion at elbow/fingers = sign of contralateral upper motor neuron weakness.

Patterns of Weakness and Their Meaning

Pattern	Likely Lesion
Unilateral upper limb extensors + lower limb flexors ("pyramidal")	Pyramidal tract (UMN)
Bilateral proximal weakness	Myopathy
Bilateral distal weakness	Peripheral neuropathy

Gait Assessment

Walk the patient (even with assistance if needed). Observe stride length, arm swing, posture, turning, starting, and stopping.

Gait Pattern	Cause
Hemiplegic	Unilateral UMN damage
Spastic (scissor)	Bilateral UMN lesions
Steppage	Footdrop (LMN/peripheral nerve)
Waddling	Proximal muscle weakness (myopathy)
Parkinsonian	Stooped, short steps, flexed arms, reduced arm swing

Normal vs. Abnormal Motor Findings

Finding	Normal	Abnormal
Tone	Moderate resistance to passive movement	Spasticity, rigidity, flaccidity
Strength	Grade 5 symmetrically	Grade ≤4, asymmetry, pronator drift
Involuntary movements	Absent	Tremor, fasciculations, chorea, tics
Gait	Fluid, symmetric	Any of the gait patterns above

UMN lesion signs: ↑ tone, ↑ reflexes, weakness in pyramidal distribution, Babinski sign LMN lesion signs: Wasting, fasciculations, ↓ tone, absent reflexes

2. SENSORY EXAMINATION

How to Perform

Requires an alert and cooperative patient. Test sequentially:

Modalities to Test

Modality	Technique	Pathway
Light touch	Wisp of cotton on major dermatomes of extremities + trunk	Dorsal column
Pin-prick (superficial pain)	Same areas tested with a pin	Spinothalamic tract
Temperature	Cool object (follows same pathway as pain)	Spinothalamic tract
Vibration	128-Hz tuning fork on bony prominences; patient identifies when vibration stops	Dorsal column
Proprioception (joint position)	Grasp digit on its sides, move up/down; patient identifies direction — even very slight movement should be detected (great toe and distal thumb)	Dorsal column

For myelopathy: Move tuning fork up spinous processes to identify a vibration level.

Cortical/Integrated Sensations (test only if primary sensation is intact)

Test	Technique
Stereognosis	Place small familiar objects in patient's hand; identify without looking
Graphesthesia	Write numbers on patient's palm; identify
Two-point discrimination	Distinguish two closely applied stimuli
Double simultaneous stimulation	Apply light touch bilaterally; patient should report both

Romberg Test

Patient stands with feet together, then closes eyes. Positive = falls with eyes closed → indicates proprioceptive loss (peripheral or posterior column lesion) or vestibular/cerebellar disease.

Dermatome Reference (Key Landmarks)

Root	Region
C5–6	Lateral upper limb; C6 = thumb
C8	Ring/little fingers
T4	Nipple level
T10	Umbilicus
L1	Groin/inguinal
L4–5, S1	Foot
S2–4	Perineum

Normal vs. Abnormal Sensory Findings

Finding	Normal	Abnormal
Light touch	Felt symmetrically	Dermatomal loss, distal-to-proximal gradient
Proprioception	Detects smallest movements	Loss → dorsal column or peripheral nerve disease
Vibration	Detected symmetrically	Loss or asymmetry → posterior column or peripheral neuropathy
Pain/temperature	Intact bilaterally	Loss with intact proprioception → hemicord (Brown-Séquard) or spinothalamic lesion

3. REFLEX EXAMINATION

Deep Tendon Reflexes (DTRs)

Technique: Patient relaxed; muscle positioned midway between full contraction and extension. Test both sides sequentially. Use the Jendrassik maneuver to reinforce (e.g., clench teeth for upper limb reflexes; hook flexed fingers together and pull apart for Achilles reflex).

Reflex Grading Scale

Grade	Description
0	Absent
1	Present but diminished
2	Normal (normoactive)
3	Increased / brisker than average
4	Pathologically increased; clonus present

Standard Reflexes and Nerve Root Levels

Reflex	Root Level	How to Test
Biceps	C5, C6	Strike biceps tendon with hammer
Brachioradialis (Supinator)	C5, C6	Strike radial styloid
Triceps	C6, C7	Strike triceps tendon with elbow flexed
Finger flexors	C8, T1	Flick examiner's fingers resting on patient's fingers
Patellar (knee)	L3, L4	Strike patellar tendon below patella
Achilles (ankle)	S1, S2	Strike Achilles tendon with foot slightly dorsiflexed

Cutaneous (Superficial) Reflexes

Reflex	Technique	Normal Response	Abnormal
Plantar (Babinski)	Stroke lateral sole heel → ball → great toe with blunt object	Plantar flexion of toes	Babinski sign = extension of great toe + fanning of other toes → UMN lesion above S1. Always abnormal after age 3 years
Abdominal reflexes	Stroke each abdominal quadrant diagonally toward umbilicus	Umbilicus moves toward stimulus	Absent → UMN lesion. Preserved upper (T9) but absent lower (T12) → lesion between T9–T12
Cremasteric	Stroke medial thigh	Ipsilateral testicular elevation	Absent → L1–L2 lesion or UMN disease
Anal	Scratch perianal skin	Anal sphincter contraction	Absent → S2–S4 lesion

Primitive/Frontal Release Reflexes (abnormal if present in older children/adults)

Reflex	Technique	Indicates
Suck reflex	Touch center of lips with tongue blade	Normal in neonates; abnormal if present in older child = frontal lobe disease
Rooting reflex	Touch corner of lips	Normal in neonates; abnormal if persists = frontal pathology
Grasp reflex	Touch palm between thumb and index finger	Normal in neonates; pathological if persistent = frontal lobe disease
Palmomental reflex	Scratch diagonally across palm	Contraction of chin (mentalis) muscle = frontal lobe dysfunction

4. CEREBELLAR EXAMINATION

How to Perform (SARA Domains)

The Scale for Assessment and Rating of Ataxia (SARA) covers 8 domains:

1. Gait

Ask patient to walk normally. Look for: variable stride length, veering to one side (early), wide-based gait (moderate–severe). Have children run or climb stairs to detect subtle difficulty.

2. Stance

Stand with feet together
Tandem stance (heel-to-toe)
Stand on each foot
Hop on each foot
Normal: stable upright posture; Abnormal: truncal sway

3. Sitting

Observe for truncal sway without back support.

4. Speech

Normal: fluent; Abnormal: scanning speech — slow, halting, with irregular force and unnecessary pauses between syllables ("staccato" speech)

5. Finger-Nose Test (Upper Limb Coordination)

Ask patient to extend arm, touch tip of nose, then touch examiner's moving index finger, repeatedly. Normal: smooth, accurate; Abnormal: intention tremor (oscillation increasing as target approaches), past-pointing (dysmetria)

6. Finger Chase Test

Patient's index finger follows examiner's moving finger. Abnormal: overshoot/undershoot (hypermetria/hypometria)

7. Rapid Alternating Movements (Dysdiadochokinesia)

Rapid pronation/supination of hand or finger tapping. Normal: smooth, rhythmic; Abnormal: slow, irregular rhythm = dysdiadochokinesia

8. Heel-Knee-Shin Test (Lower Limb Coordination)

Patient (supine) lifts leg, places heel on opposite knee, slides smoothly down the shin. Normal: smooth, accurate; Abnormal: heel falls off shin, irregular movement

Eye Movements

Normal fixation: Stable gaze without intrusion
Abnormal findings: Square-wave jerks (Friedreich ataxia), end-gaze nystagmus, saccadic pursuit, slow saccades (SCA2), hypo/hypermetric saccades

Normal vs. Abnormal Cerebellar Findings

Domain	Normal	Abnormal (Cerebellar Sign)
Gait	Smooth, narrow-based	Wide-based, veering, ataxic
Stance	Stable feet-together	Truncal sway, positive Romberg (if proprioception also affected)
Speech	Fluent, prosodic	Scanning/dysarthric
Finger-nose	Smooth, accurate	Intention tremor, dysmetria
Rapid alternating	Rhythmic	Dysdiadochokinesia
Heel-shin	Smooth	Heel falls off shin
Eyes	Stable pursuit	Nystagmus, square-wave jerks, saccadic pursuit

Summary: UMN vs. LMN vs. Cerebellar Differentiation

Feature	UMN Lesion	LMN Lesion	Cerebellar Lesion
Tone	Increased (spastic)	Decreased (flaccid)	Normal or decreased
Strength	Pyramidal pattern weakness	Focal/distal weakness	Normal strength
Reflexes	Hyperreflexia	Hyporeflexia/absent	Normal
Babinski	Positive	Negative	Negative
Fasciculations	Absent	Present	Absent
Atrophy	Mild (disuse)	Marked	Absent
Coordination	Impaired (due to weakness)	Normal or impaired	Markedly impaired (ipsilateral)
Gait	Spastic/hemiplegic	Steppage/waddling	Wide-based/ataxic

Sources: Textbook of Family Medicine 9e; Harrison's Principles of Internal Medicine 22E; Bradley and Daroff's Neurology in Clinical Practice; Adams and Victor's Principles of Neurology 12E

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