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Upper
extremities – Inspection & Palpation
In this patient there are fasciculations (spontaneous contraction
of a motor unit) noted in the deltoid muscle as well as atrophy. There is
also atrophy of the interosseous muscles of the hands. These findings can
be seen in motor neuron disease such as amyotrophic lateral sclerosis. |
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Tone
There is increased tone in the right upper extremity that is rate dependent
with the clasp-knife phenomena noted when the arm is flexed. This is spasticity
from an upper motor neuron lesion. |
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Strength
testing
With an UMN lesion the fine, fractionated movements of the fingers and hand
are lost. Distal extremity weakness is greater than proximal weakness. With
greater effort to move the paretic hand, there is overflow activation of
proximal muscles and even of the contralateral hand, which produces mirror
or synkinetic movements. |
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Stretch
or Deep Tendon Reflexes
It is always
important to compare right vs. left. The first patient shown has hyperreflexia
or 3+ DTR's of the right biceps, triceps and brachioradialis. The second
patient has hyperreflexia of the right finger flexors. Hyperreflexia is
one of the signs of a UMN lesion.
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Testing
for pronator drift
With an UMN lesion there is pronation and downward drift of the outstretched
supinated arm. This is because the pronators overpower the weaker supinators.
Another name for this sign is a pronator Babinski. |
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Lower
extremities – Inspection & Palpation
There is hypertrophy of this patient's left leg. Closer inspection of that
extremity shows hyperpigmented skin lesions suggesting segmental neurofibromatosis.
A thorough skin search can provide important clues to diagnosis especially
in the neurocutaneous syndromes. |
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Video
Courtesy of Alejandro Stern, Stern Foundation
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Tone
There is spasticity on passive range of motion of the patient's right ankle
with decrease range of motion and clonus which is caused by repetitive contraction
of the stretched gastrocnemius muscle. Range of motion at the knee would
also demonstrate spasticity. These findings are part of the UMN syndrome.
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Strength
testing
Testing of the muscle strength in this patient shows 1/5 weakness of dorsiflexion,
plantar flexion, inversion and eversion of the right ankle with normal proximal
strength. |
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Stretch
or Deep Tendon Reflexes
There is hyperreflexia of the right knee jerk (3+) with a rightsided crossed
adductor response (the crossed adductor contraction occurred because of
the increased right leg tone which resulted in reflex contraction of the
adductor magnus with the very slight stretch of this muscle caused by tapping
the opposite knee). There is also hyperreflexia with clonus (4+ DTR) of
the right ankle. The second patient demonstrates a 4+ ankle jerk on the
left with sustained clonus.
Hyperreflexia is one of the signs of the UMN syndrome. |
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Plantar
Reflex
The patient has a Babinski sign on the right with an up going great toe
and dorsiflexion and fanning of the other toes. This is an important indication
of UMN disease. |
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Pathological reflexes-
frontal release signs- snout, root, palmomental
These patterned behavior reflexes appear when there is damage to the frontal
lobes, which normally inhibits these primitive reflexes.
A snout reflex
occurs when a tongue blade is pressed on the lips and there is pouting
of the lips.
A root reflex
occurs when gently stroking the lateral upper lip causes the mouth to
moves toward the stimuli.
A palmomental
reflex occurs when stroking the palm of the hand causes the ipsilateral
mentalis muscle of the lower lip to contract.
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Strength
testing using squat & rise, heel & toe
This patient has proximal pelvic girdle weakness which is demonstrated by
his using his hands to climb the wall and then pushing on his thighs to
get his trunk upright. When a patient uses his hands to climb up his legs
to get to a standing position is this called a Gowers' sign. |
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