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Motor Examination in Neurological Assessment — Step-by-Step Guide

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PREPARATION

• Position the patient comfortably, ideally supine or seated
• Expose the limbs adequately for inspection
• Explain each step to gain cooperation
• Compare right vs. left and upper vs. lower limbs throughout

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STEP 1 — INSPECTION (Look Before You Touch)

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STEP 2 — MUSCLE TONE

1. Ask the patient to fully relax — "Let your arm go completely floppy."
2. Support the limb and passively move each joint through full range in an unpredictable rhythm (vary speed and direction to avoid voluntary cooperation).

Tip: To unmask subtle cogwheeling, ask the patient to move the other hand while you passively move the tested wrist.

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STEP 3 — MUSCLE POWER (MRC Scale)

MRC Power Grading Scale

Upper Limb Muscles to Test

Lower Limb Muscles to Test

Pronator drift test: Ask the patient to hold both arms outstretched, palms up, eyes closed. A pyramidal (UMN) lesion causes the arm to pronate and drift downward on the affected side.

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STEP 4 — DEEP TENDON REFLEXES (DTRs)

Reflex Grading Scale

Reflexes and Their Root Levels

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STEP 5 — PLANTAR RESPONSE (Babinski Sign)

1. Use a blunt object (key or stick end of reflex hammer)
2. Stroke firmly from the lateral heel along the lateral sole, then curve medially under the metatarsal heads
3. Observe the big toe response

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STEP 6 — COORDINATION

Upper Limb

1. Ask the patient to fully extend the arm
2. Touch the tip of their nose, then touch the examiner's index finger (held at arm's length)
3. Repeat after the examiner moves the target finger to a new location

• Ask the patient to perform rapid alternating hand movements (pronate/supinate rapidly on the other palm)
• Cerebellar lesion → irregular, slow, clumsy

Lower Limb

1. Patient lies supine
2. Place heel on the opposite knee
3. Slide the heel smoothly down the shin to the ankle
4. Repeat; assess smoothness and accuracy

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STEP 7 — GAIT ASSESSMENT

• Tandem walking (heel-to-toe in a straight line) — uncovers subtle cerebellar ataxia
• Walking on heels — tests L4/L5 (tibialis anterior)
• Walking on tiptoes — tests S1 (gastrocnemius)
• Romberg test: Stand feet together; positive if patient falls/sways markedly with eyes closed → dorsal column or peripheral proprioceptive loss

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STEP 8 — INTEGRATION: UMN vs. LMN Localisation

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CLINICAL PEARL: Functional Weakness

• Normal tone
• Normal reflexes
• No wasting
• Erratic, variable power (give-way weakness)

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MOTOR EXAMINATION IN NEUROLOGY — COMPLETE STEP-BY-STEP DETAIL

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STEP 1 — INSPECTION (LOOK BEFORE YOU TOUCH)

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1A. PREPARATION FOR INSPECTION

• Ensure the room is well-lit — fasciculations are invisible in dim light
• Ask the patient to undress to underwear so all four limbs and trunk are visible
• Position the patient comfortably supine initially, then seated
• Stand back at least 1–2 metres for a panoramic view first
• Tell the patient: "I am going to look at your muscles before I test them. Please stay relaxed."

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1B. INSPECT THE WHOLE BODY POSTURE FIRST

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1C. INSPECT FOR MUSCLE WASTING (ATROPHY)

1. Compare the same muscle group on both sides simultaneously
2. Look for hollowing, loss of normal contour, prominent bony landmarks

Grading wasting: Document as mild, moderate, or severe. Note whether it is focal (single nerve or root), distal (peripheral neuropathy), proximal (myopathy), or hemibody (UMN).

• Significant wasting = LMN lesion (nerve, root, anterior horn cell) or primary muscle disease
• UMN lesions produce only mild disuse atrophy over months — never the severe hollowing of a LMN lesion

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1D. INSPECT FOR FASCICULATIONS

1. The patient must be completely at rest and the room must be well-lit (tangential lighting helps)
2. Watch each muscle group for at least 15–30 seconds before moving on
3. Ask the patient not to contract the muscle — fasciculations appear at rest
4. Gently tapping a muscle may provoke fasciculations if denervation is present

• Tongue (ask patient to rest tongue on floor of mouth — do NOT protrude, as movement mimics fasciculations)
• Thenar/hypothenar eminences
• Deltoid
• Quadriceps (large, easy to see)
• Calf

Key rule: Fasciculations are never seen in pure UMN lesions.

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1E. INSPECT FOR INVOLUNTARY MOVEMENTS

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1F. INSPECT THE SKIN, JOINTS, AND DEFORMITIES

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STEP 2 — MUSCLE TONE

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2A. PRINCIPLES

• Tone = the resistance of a muscle to passive stretch at rest
• It reflects the integrity of the reflex arc + supraspinal control
• The patient must be completely relaxed — actively distract them during testing
• Move joints at varying speeds and in unpredictable directions to prevent voluntary assistance

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2B. UPPER LIMB TONE — STEP BY STEP

1. Support the patient's forearm with one hand
2. Hold the patient's hand with your other hand as if shaking hands
3. Pronate and supinate the wrist repeatedly at varying speeds
4. Feel for resistance throughout the range

1. Cup the patient's hand
2. Flex and extend the wrist passively, varying speed
3. Normal: slight springy resistance throughout

1. Support the forearm and flex/extend the elbow
2. Do this at different speeds — spasticity is velocity-dependent

1. Hold the upper arm and gently internally/externally rotate and abduct
2. Useful for detecting shoulder rigidity in Parkinson's

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2C. LOWER LIMB TONE — STEP BY STEP

1. Patient lies supine, legs extended
2. Place both hands on the thigh and briskly roll the leg internally and externally
3. Watch the foot — it should oscillate freely
4. In spasticity, the foot does not oscillate freely and moves rigidly with the leg

1. Place both hands behind the patient's knee
2. Rapidly lift the knee off the table
3. Observe the heel:
   • Normal: heel drags along the table surface for a variable distance before lifting
   • Increased tone (spasticity): heel lifts immediately with the knee — no drag
   • Decreased tone (flaccidity): heel stays on the table even as you lift fully

1. With the knee slightly flexed, place your hand under the ankle
2. Dorsiflex the foot rapidly and sustain the stretch
3. Sustained rhythmic beats = clonus — indicates UMN lesion (corticospinal tract damage)
4. Count the beats — more than 5 sustained beats = pathological clonus

1. Patient lies flat with leg extended
2. Push the patella sharply downward and hold
3. Rhythmic patellar oscillation = patellar clonus — UMN sign

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2D. TYPES OF ABNORMAL TONE — DETAILED

To bring out cogwheel rigidity: Ask the patient to move the opposite hand (e.g., open and close it) while you assess the tested wrist — this "reinforcement" makes subtle cogwheeling much more apparent. — Harrison's Principles of Internal Medicine, 22e

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STEP 3 — MUSCLE POWER (STRENGTH)

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3A. PRINCIPLES

• Always isolate the muscle being tested — stabilise the proximal joint
• Apply resistance in the direction opposing the movement
• Ask for maximum effort: "Push as hard as you can — don't let me move you"
• Palpate the contracting muscle while testing — confirms effort and contraction quality
• Compare left vs. right at each level
• Grade using the MRC Scale

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3B. MRC POWER GRADING — DETAILED

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3C. PRONATOR DRIFT TEST — SCREEN FOR UMN WEAKNESS

1. Ask the patient to hold both arms fully outstretched, palms facing upward (supinated), parallel to the floor
2. Ask them to close their eyes
3. Hold this position for 10 seconds
4. Watch carefully for any:
   • Pronation of the forearm (palm turns down)
   • Downward drift of the entire arm
   • Finger flexion

"Testing for pronator drift is an extremely useful method for screening upper limb weakness." — Harrison's, 22e

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3D. UPPER LIMB POWER — STEP-BY-STEP MUSCLE TESTING

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Shoulder Abduction (C5, Axillary nerve)

• Position: Patient seated, arm at 90° abduction
• Your hand: Place on the lateral upper arm
• Command: "Hold your arm up — don't let me push it down"
• Resistance: Push the arm downward toward the side

Shoulder Adduction (C6–C7, Pectoral nerve)

• Position: Arm at 90° abduction
• Command: "Push your arm into your side — don't let me pull it out"
• Resistance: Pull the arm outward

Elbow Flexion (C5–C6, Musculocutaneous nerve — Biceps)

• Position: Elbow at 90°, forearm supinated
• Your hand: Grasp the wrist
• Command: "Bend your elbow — don't let me straighten it"
• Resistance: Pull the forearm downward (extending the elbow)

Elbow Extension (C7, Radial nerve — Triceps)

• Position: Elbow at 90°, forearm pronated
• Command: "Straighten your arm — don't let me bend it"
• Resistance: Push the forearm upward (flexing the elbow)

Wrist Extension (C6–C7, Radial nerve)

• Position: Forearm pronated, fist loosely closed
• Command: "Cock your wrist back — don't let me push it forward"
• Resistance: Push the dorsum of the hand into flexion

Wrist Flexion (C7–C8, Median/Ulnar nerve)

• Command: "Flex your wrist — don't let me pull it back"
• Resistance: Push the palm into extension

Finger Extension (C7, Posterior interosseous nerve)

• Position: Fingers extended at MCP joints
• Command: "Keep your fingers straight — don't let me bend them"
• Resistance: Push fingers into flexion at MCP joints

Finger Flexion (C8, Median/Ulnar nerve)

• Command: "Squeeze my fingers as hard as you can"
• Insert two fingers into the patient's fist — assess grip strength

Finger Abduction / Interossei (T1, Ulnar nerve)

• Position: Hand flat on a surface, fingers extended
• Command: "Spread your fingers apart — don't let me push them together"
• Resistance: Push middle and index finger together

Thumb Opposition (T1, Median nerve — Thenar muscles)

• Command: "Touch your little finger with your thumb — keep them together"
• Try to pull the thumb away from the little finger

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3E. LOWER LIMB POWER — STEP-BY-STEP MUSCLE TESTING

Hip Flexion (L1–L2, Femoral nerve — Iliopsoas)

• Position: Patient supine, hip flexed to 30°
• Command: "Lift your leg off the bed — don't let me push it down"
• Resistance: Push the thigh downward

Hip Extension (S1, Inferior gluteal nerve — Gluteus maximus)

• Position: Patient supine, leg flat
• Command: "Push your heel down into the bed — don't let me lift your leg"
• Or: prone — "Lift your straight leg off the bed"

Hip Abduction (L4–L5, Superior gluteal nerve — Gluteus medius)

• Position: Supine, legs flat
• Command: "Push your leg out to the side — don't let me push it in"
• Resistance: Push the lateral thigh inward

Hip Adduction (L2–L3, Obturator nerve)

• Command: "Squeeze your legs together — don't let me pull them apart"

Knee Extension (L3–L4, Femoral nerve — Quadriceps)

• Position: Seated or supine with knee at 90°
• Command: "Straighten your knee — don't let me bend it"
• Resistance: Push the lower leg into flexion

Knee Flexion (S1, Sciatic nerve — Hamstrings)

• Position: Prone or supine with knee slightly flexed
• Command: "Bend your knee — don't let me straighten it"
• Resistance: Pull the lower leg into extension

Ankle Dorsiflexion (L4–L5, Deep peroneal nerve — Tibialis anterior)

• Command: "Pull your foot up toward you — don't let me push it down"
• Resistance: Push down on the dorsum of the foot
• Weakness = footdrop, steppage gait

Ankle Plantarflexion (S1–S2, Tibial nerve — Gastrocnemius/Soleus)

• Command: "Push your foot down like pressing a pedal — don't let me pull it up"
• Resistance: Push upward on the sole
• Also test: can the patient stand on tiptoe on each foot in turn?

Great Toe Extension (L5, Deep peroneal nerve — Extensor hallucis longus)

• Command: "Pull your big toe up — don't let me push it down"
• Resistance: Push the big toe into plantarflexion

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3F. RECOGNISING WEAKNESS PATTERNS

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STEP 4 — DEEP TENDON REFLEXES (DTRs)

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4A. PRINCIPLES

• The patient must be relaxed — contracted muscles abolish reflexes
• Use a proper tendon hammer (Babinski or Queen Square hammer)
• Strike the tendon (not the muscle belly) with a brisk, relaxed wrist flick
• Assess the smallest stimulus needed to elicit the reflex, not the maximum response
• Always compare left vs. right at each level
• If absent, use Jendrassik manoeuvre before concluding the reflex is truly absent

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4B. JENDRASSIK MANOEUVRE (Reinforcement)

• Ask the patient to interlock their fingers of both hands and pull them apart vigorously
• While they are pulling — strike the tendon
• This reduces cortical inhibition and unmasks suppressed reflexes

• Ask the patient to clench their teeth or clench the opposite fist

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4C. REFLEX GRADING SCALE

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4D. UPPER LIMB REFLEXES — HOW TO ELICIT EACH

Biceps Reflex (C5, C6)

1. Patient's arm relaxed, elbow at 90° flexion, forearm slightly pronated (resting on your arm)
2. Place your thumb firmly over the biceps tendon (in the antecubital fossa)
3. Strike your thumb with the hammer — not the patient directly
4. Normal response: Biceps contracts → elbow flexion + slight supination
5. Absent: C5/C6 lesion
6. Exaggerated: UMN lesion above C5

Supinator (Brachioradialis) Reflex (C5, C6)

1. Patient's arm relaxed, elbow at 90°, forearm in mid-pronation (thumb up)
2. Strike the radial border of the forearm 4–5 cm above the wrist
3. Normal response: Forearm flexion + slight supination
4. Inverted supinator reflex: No contraction here but fingers flex → C5/C6 root lesion with intact C8 reflex arc — significant for cord lesion at C5/C6

Triceps Reflex (C6, C7)

1. Support the patient's arm with elbow at 90° flexion, arm hanging freely
2. Strike the triceps tendon directly above the olecranon
3. Normal response: Elbow extension
4. Absent: C7 lesion

Finger Flexor Reflex (C8, T1)

1. Hold the patient's hand with their fingers slightly flexed over your fingers
2. Strike the dorsal surface of your fingers
3. Normal: Slight finger flexion
4. Exaggerated: Pathological — Hoffmann's sign equivalent; UMN
5. Hoffmann's sign: Flick the middle fingernail downward and release — thumb and index finger flex involuntarily = UMN sign

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4E. LOWER LIMB REFLEXES — HOW TO ELICIT EACH

Knee (Patellar) Reflex (L3, L4)

1. Patient sits with legs hanging freely at 90° off the bed edge
2. Strike the patellar tendon just below the patella with a brisk swing
3. Normal: Knee extension (quadriceps contraction)

1. Support the knee with your non-dominant arm underneath, creating a 30° knee flex
2. Strike the patellar tendon
3. Watch for quadriceps contraction and knee extension

Ankle (Achilles) Reflex (S1, S2)

1. Ask the patient to kneel on the examination couch with feet hanging over the edge
2. Slightly dorsiflex the foot to put the tendon under mild tension
3. Strike the Achilles tendon directly, above the heel

1. Cross the tested leg over the opposite shin ("figure-4")
2. Gently dorsiflex the foot
3. Strike the Achilles tendon

1. Flex the hip and knee, let the leg fall laterally
2. Apply passive dorsiflexion, then strike

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4F. CUTANEOUS (SUPERFICIAL) REFLEXES

Plantar Reflex / Babinski Sign

1. Position the patient's leg in external rotation, knee slightly flexed
2. Warn the patient: "I'm going to stroke the sole of your foot — it may feel uncomfortable"
3. Use the blunt handle of the hammer or a key
4. Apply firm, continuous pressure from the lateral heel, along the lateral sole, then curve medially toward the ball of the foot under the toes
5. The stroke should take 2–3 seconds — not too fast, not too slow

Abdominal Reflexes (T7–T12)

1. With the patient supine, use a pointed object to stroke from the lateral abdomen toward the midline in each quadrant
2. Normal: Umbilicus moves toward the quadrant stroked
3. Absent unilaterally above umbilicus (T8–T9) but present below: Spinal cord lesion at T8–T9
4. Absent ipsilaterally: UMN lesion above that level
5. Absent in obesity and post-abdominal surgery — not always pathological

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4G. PRIMITIVE REFLEXES (Frontal Release Signs)

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STEP 5 — COORDINATION

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5A. PRINCIPLES

• Coordination tests the cerebellar system (vermis = truncal/gait; hemispheres = limb)
• Only meaningful if the patient has adequate power (MRC ≥ 3) and adequate sensation
• Weakness and sensory loss cause incoordination that is NOT cerebellar — always interpret in context

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5B. UPPER LIMB COORDINATION

Finger-to-Nose Test

1. Hold your index finger at the patient's arm's length away, slightly off-centre
2. Ask: "Touch the tip of your nose with your index finger, then touch my finger — and keep going back and forth"
3. After several cycles, move your finger to a new position without warning
4. The patient must reach accurately to the new position each time
5. Observe for:
   • Dysmetria: Past-pointing (overshooting) or under-shooting the target
   • Intention tremor: Tremor that increases as the finger approaches the target (absent at rest)
   • Decomposition of movement: Movement breaks into jerky segments

Rapid Alternating Movements (Dysdiadochokinesia)

1. Ask the patient to tap the back of one hand alternately with the palm and dorsum of the other hand as rapidly as possible
2. Observe for rhythm, regularity, and speed

1. Ask the patient to tap their index finger to the thumb repeatedly at speed
2. Compare both hands

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5C. LOWER LIMB COORDINATION

Heel-Knee-Shin Test

1. Patient lies supine, legs flat
2. Ask: "Lift your right heel and place it on your left knee"
3. Then: "Now slide your heel smoothly down your shin toward your ankle"
4. Return to start and repeat several times
5. Observe for:
   • Accuracy of placing heel on knee
   • Smoothness of sliding down the shin (should be in a straight line)
   • Deviations / wobbling off the shin
   • Slowing of initiation

Foot Tapping

• Ask patient to tap the foot (heel on floor, foot tapping up and down) as fast and regularly as possible
• Compare both sides — unilateral slowing = ipsilateral cerebellar or contralateral UMN

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5D. CEREBELLAR SIGNS SUMMARY

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STEP 6 — GAIT AND BALANCE

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6A. PRINCIPLES

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6B. HOW TO ASSESS GAIT — STEP BY STEP

1. Ask the patient to walk to the end of the corridor and back
2. Observe from behind initially, then from the side
3. Assess:
   • Stride length (normal vs. short steps)
   • Base width (narrow normal vs. wide-based)
   • Arm swing — normally symmetrical
   • Posture — upright vs. stooped
   • Rhythm and regularity
   • Turning — normal vs. turns en bloc (Parkinson's)
   • Foot clearance — does the foot drag? Does the toe drop?

• Walk on heels down the corridor
• Tests L4/L5 (tibialis anterior — dorsiflexion)
• Inability = footdrop / L5 weakness

• Walk on tiptoes
• Tests S1 (gastrocnemius — plantarflexion)
• Inability = S1 weakness

• Walk in a straight line placing each foot directly in front of the other
• This is the most sensitive test for cerebellar ataxia (small abnormalities not visible in normal walking)
• Patient holds arms out if needed for balance

1. Ask the patient to stand with feet together, arms by their sides
2. Observe stability with eyes open first
3. Then ask the patient to close their eyes
4. Stand close to prevent falls

Important: A positive Romberg is NOT a cerebellar test — it is a sign of sensory ataxia (posterior column / peripheral nerve proprioception failure). Cerebellar ataxia is present with eyes OPEN and does not worsen dramatically on closing.

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6C. SPECIFIC GAIT PATTERNS — DETAILED RECOGNITION

1. Hemiplegic Gait (UMN — unilateral)

• What you see: Affected arm held flexed and adducted; affected leg extended and stiff, swings in a semicircle outward (circumduction) to clear the floor
• Arm swing: Absent on affected side
• Cause: Contralateral cortical or capsular lesion, stroke

2. Spastic ("Scissor") Gait (UMN — bilateral)

• What you see: Both legs stiff, adducted, knees brush against each other ("scissors"), short shuffling steps on tiptoe
• Cause: Bilateral UMN — bilateral cortical lesions, cervical myelopathy, cerebral palsy

3. Steppage (Footdrop) Gait (LMN)

• What you see: Exaggerated hip and knee flexion to lift the foot off the ground; foot slaps down on landing; toe drags otherwise
• Cause: L4/L5 radiculopathy, common peroneal nerve palsy, Charcot-Marie-Tooth

4. Waddling Gait (Proximal muscle weakness)

• What you see: Trunk sways side-to-side; "duck-like"; pelvis drops on the unsupported side (Trendelenburg sign)
• Cause: Proximal myopathy (muscular dystrophy), hip girdle weakness

5. Parkinsonian Gait (Extrapyramidal)

• What you see:
  • Stooped posture, head and trunk flexed forward
  • Shuffling, very small steps (marche à petit pas)
  • Reduced/absent arm swing bilaterally
  • Festination: Progressively faster, shorter steps — patient accelerates involuntarily
  • Start hesitation: Difficulty initiating movement
  • Freezing: Feet appear glued to the floor, especially in doorways
  • Turning en bloc: Cannot pivot; turns in multiple small steps
• Cause: Parkinson's disease, Parkinson-plus syndromes

6. Cerebellar (Ataxic) Gait

• What you see: Wide-based, unsteady, staggering — patient sways erratically; like a drunk person
• Not improved by opening eyes (unlike sensory ataxia)
• Difficulty or impossible with tandem walking
• Cause: Cerebellar vermis lesion (alcohol, MS, tumour, stroke)

7. Sensory Ataxic Gait (Posterior column)

• What you see: Wide-based, stamping / high-stepping gait; patient watches the floor; markedly worse in the dark or with eyes closed
• Cause: Posterior column lesion (B12 deficiency, tabes dorsalis, sensory neuropathy)

8. Antalgic Gait (Pain-related)

• Rapid transfer of weight off the painful limb; shortened stance phase on affected side

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INTEGRATION TABLE — UMN vs LMN vs CEREBELLAR

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TONE ASSESSMENT & SPASTICITY — COMPLETE DETAILED GUIDE

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PART 1 — MUSCLE TONE: WHAT IT IS

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• Stretch reflex arc (muscle spindle → Ia afferent → alpha motor neuron → muscle)
• Supraspinal control (corticospinal, reticulospinal, vestibulospinal tracts)

"Tone is the resistance of a muscle to passive stretch. Increased tone may be of several types." — Harrison's Principles of Internal Medicine, 22e

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PART 2 — HOW TO ASSESS TONE PROPERLY (STEP BY STEP)

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GOLDEN RULES BEFORE YOU START

1. The patient must be completely relaxed — this is the single most critical requirement
2. Distract the patient — talk to them, ask a question, have them name days of the week — this prevents voluntary muscle bracing
3. Move joints at varying speeds and in unpredictable directions — prevents anticipatory voluntary movement
4. Never announce what you are about to do next
5. Always compare left vs. right at every joint
6. Assess proximal → distal systematically

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STEP 1 — POSITIONING

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STEP 2 — UPPER LIMB TONE ASSESSMENT

A. Wrist Pronation/Supination

1. Cradle the patient's forearm with your non-dominant hand
2. Grip their hand as if shaking hands with your dominant hand
3. Pronate and supinate the wrist repeatedly at varying, unpredictable speeds
4. Feel the resistance through your grip
5. Normal: Slight, yielding spring-like resistance

B. Wrist Flexion/Extension

1. Cup the dorsum of the patient's hand in your palm
2. Flex and extend the wrist through full range
3. Vary speed — slow then fast
4. Key: At fast speed, spasticity reveals itself (velocity-dependent catch)

C. Elbow Flexion/Extension

1. Support the forearm; grasp the wrist
2. Flex and extend the elbow through full range
3. Vary speed — first slow, then fast
4. In spasticity: resistance is felt prominently in extension (flexors of UL are antigravity muscles and are spastic)

D. Shoulder

1. Hold the upper arm gently
2. Internally and externally rotate the shoulder
3. Gently abduct the arm
4. Useful for detecting shoulder rigidity in Parkinson's

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STEP 3 — LOWER LIMB TONE ASSESSMENT

A. Leg Roll Test (best screening test)

1. Patient lies supine, both legs extended flat
2. Place both your hands on top of the patient's thigh
3. Briskly roll the leg inward and outward (internal/external rotation at the hip)
4. Watch the foot — it should oscillate loosely and freely
5. Normal: Foot swings freely like a pendulum
6. Increased tone: Foot moves rigidly with the leg — little or no foot oscillation

B. Knee Lift Test (Harrison's method)

1. Place both hands behind the patient's knee
2. Rapidly and briskly lift the knee upward off the table
3. Watch the heel:

C. Ankle Dorsiflexion

1. Support the ankle with one hand under the heel
2. With your other hand, slowly then quickly dorsiflex the foot
3. Compare slow vs. fast — spasticity is velocity-dependent; rigidity is not

D. Clonus Testing (always test when you suspect increased tone)

1. Support the knee in slight flexion with one hand
2. With the other hand, grip the sole of the foot
3. Apply a sudden, sustained dorsiflexion jerk — hold the position firmly
4. Count the rhythmic beats (contractions) of the calf muscle

1. Leg extended flat
2. Grasp the patella between your index finger and thumb
3. Push it sharply downward and sustain the push
4. Feel for rhythmic oscillation under your fingers

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STEP 4 — RECORDING TONE

• Which limb(s) are affected
• Type of abnormality (spasticity / rigidity / flaccidity / paratonia)
• Distribution (proximal, distal, hemibody, generalised)
• Severity (mild / moderate / severe or use a grading scale)
• Clonus (present/absent, sustained/unsustained, number of beats)

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PART 3 — TYPES OF ABNORMAL TONE (COMPLETE)

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TYPE 1 — SPASTICITY

"Spasticity is the increase in tone associated with disease of upper motor neurons. It is velocity dependent, has a sudden release after reaching a maximum (the 'clasp-knife' phenomenon), and predominantly affects the antigravity muscles." — Harrison's, 22e

• Velocity-dependent — faster stretch = more resistance (this is the hallmark)
• Clasp-knife character — initial catch then sudden release, like closing a penknife
• Predominantly affects antigravity muscles:
  • Upper limb flexors (elbow flexors, wrist flexors, finger flexors)
  • Lower limb extensors (quadriceps, plantarflexors)
• Associated with hyperreflexia, Babinski sign, clonus
• Develops days to weeks after acute UMN lesion (initially flaccid in acute phase)

• UL: Shoulder adductors, elbow flexors, wrist/finger flexors, pronators
• LL: Hip extensors/adductors, knee extensors, ankle plantarflexors/invertors

• Upper limb: adducted shoulder, flexed elbow, pronated forearm, flexed wrist and fingers
• Lower limb: extended knee, plantarflexed/inverted ankle, extended hip

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TYPE 2 — RIGIDITY

"Rigidity is hypertonia that is present throughout the range of motion (a 'lead pipe' or 'plastic' stiffness) and affects flexors and extensors equally." — Harrison's, 22e

• NOT velocity-dependent — resistance is the same whether you move fast or slow
• Equal in both flexors and extensors throughout the full range of motion ("plastic")
• "Lead pipe" feel — like bending a soft metal rod
• Does NOT have a clasp-knife give
• Associated with bradykinesia, tremor (Parkinson's), not with hyperreflexia

• Rigidity + superimposed ratchet-like interruptions = cogwheeling
• Best felt at the wrist during pronation/supination
• Caused by tremor superimposed on rigidity
• To unmask: ask the patient to move the contralateral hand while you test — reinforcement makes cogwheeling appear

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TYPE 3 — PARATONIA (GEGENHALTEN)

"Paratonía (or gegenhalten) is increased tone that varies irregularly in a manner seemingly related to the degree of relaxation, present throughout the range of motion, and affects flexors and extensors equally." — Harrison's, 22e

• Patient seems to involuntarily resist movement regardless of instruction to relax
• Resistance is inconsistent and irregular — varies moment to moment
• Cannot be overcome by reassurance or distraction
• Affects both directions of movement

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TYPE 4 — FLACCIDITY / HYPOTONIA

"Weakness with decreased tone (flaccidity) occurs with disorders of motor units." — Harrison's, 22e

• No resistance to passive movement — limb feels heavy and dead
• Limb drops if unsupported
• Heel drag test: heel stays on table even when you lift fully
• Leg roll test: foot flops excessively
• Associated with: hyporeflexia/areflexia, wasting, fasciculations

• LMN lesion (anterior horn cell, root, peripheral nerve)
• Primary muscle disease (myopathy, myositis)
• Cerebellar disease (mild hypotonia)
• Acute UMN lesion (spinal shock — initially flaccid before spasticity develops)
• Neuromuscular junction disease (myasthenia gravis)

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COMPARISON TABLE — ALL TONE TYPES

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PART 4 — SPASTICITY GRADING SCALES

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SCALE 1 — MODIFIED ASHWORTH SCALE (MAS)

The Most Widely Used Clinical Scale

1. Patient relaxed, limb in the starting position
2. Move the limb through its full range of motion at a consistent, moderate speed (approximately 1 second to complete the movement)
3. For elbow spasticity: Move from full flexion to full extension in 1 second
4. For wrist: Move from full flexion to full extension in 1 second
5. For ankle: Move from full plantarflexion to dorsiflexion in 1 second
6. Feel the resistance throughout the movement and grade as below

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MODIFIED ASHWORTH SCALE — FULL GRADING

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MAS Practical Example — Elbow Flexors

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SCALE 2 — MODIFIED TARDIEU SCALE (MTS)

More Physiologically Valid — Captures Velocity-Dependence

The Tardieu Scale specifically tests the velocity-dependent nature of spasticity — the defining pathophysiological feature — making it more accurate than the Ashworth Scale.

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THE THREE VELOCITIES

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MODIFIED TARDIEU SCALE — QUALITY OF MUSCLE REACTION (X Score)

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HOW TO PERFORM THE TARDIEU SCALE — STEP BY STEP

1. Patient supine, knee slightly flexed (isolates soleus) or extended (isolates gastrocnemius)
2. Move foot very slowly (gravity-assisted, no stretch reflex activated)
3. Take the ankle from full plantarflexion to maximum dorsiflexion without resistance from spasticity
4. Record the angle of full passive range = R2

1. Same starting position
2. Move the foot as fast as possible — faster than the natural speed of falling
3. Note the angle at which you feel the catch (sudden resistance from stretch reflex)
4. Record this angle = R1

Spasticity Angle = R2 − R1

• Large angle (e.g. R2=30°, R1=0°, angle=30°): Significant spasticity
• Small angle (near zero): Mild or no spasticity
• If R1 = R2: No velocity-dependent component — suggests contracture rather than spasticity

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MAS vs. MTS — WHICH TO USE?

• Use MAS for routine clinical assessment and monitoring progress
• Use MTS when planning botulinum toxin injections, surgery, or when contracture vs. spasticity needs to be distinguished

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PART 5 — SPASTICITY vs. CONTRACTURE (CRITICAL DISTINCTION)

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PART 6 — CONSEQUENCES OF SEVERE SPASTICITY

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• Contractures — fixed shortening of muscles and tendons
• Joint deformities — equinovarus foot, hip adductor scissoring, flexed elbow
• Pressure sores — from abnormal posture and immobility
• Pain — from sustained muscle overactivity
• Flexor/extensor spasms — especially with spinal cord lesions
• Bladder/bowel dysfunction (in spinal lesions with severe spasms)
• Functional loss — inability to dress, transfer, walk, use hands

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SUMMARY QUICK REFERENCE

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TONE ASSESSMENT
│
├── NORMAL → Slight spring-like resistance
│
├── INCREASED
│   ├── SPASTICITY → Velocity-dependent, clasp-knife, UMN
│   │   Grade with: MAS (0–4) or MTS (R1/R2 + quality 0–5)
│   │
│   ├── RIGIDITY → Velocity-independent, plastic/lead-pipe, extrapyramidal
│   │   + Cogwheeling → Parkinson's (rigidity + tremor)
│   │
│   └── PARATONIA → Irregular, variable, frontal lobe disease
│
└── DECREASED
    └── FLACCIDITY / HYPOTONIA → LMN, myopathy, acute UMN (shock)

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