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EXAMINATION OF THEEXAMINATION OF THE
CENTRAL NERVOUSCENTRAL NERVOUS
SYSTEM(CNS)SYSTEM(CNS)
MOTOR NERVOUS SYSTEMMOTOR NERVOUS SYSTEM
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CNS EXAMINATIONCNS EXAMINATION
Higher Mental Functions (HMF)Higher Mental Functions (HMF)
Examination of the Unconscious PatientExamination of the Unconscious Patient
Cranial Nerves ExaminationCranial Nerves Examination Examination of the Motor Nervous SystemExamination of the Motor Nervous System
Examination of the Sensory Nervous SystemExamination of the Sensory Nervous System
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CNS EXAMCNS EXAM
The nervous system is broadly divided into theThe nervous system is broadly divided into the
central and peripheral nervous systemscentral and peripheral nervous systems
The CNS consists of the Brain & Spinal cordThe CNS consists of the Brain & Spinal cord
The Peripheral nervous system consists of theThe Peripheral nervous system consists of theperipheral nervesperipheral nerves
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BRAINBRAIN
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SPINAL CORDSPINAL CORD
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
To determine if there are any abnormalitiesTo determine if there are any abnormalities
To determine the location of such abnormalitiesTo determine the location of such abnormalities
To determine the degree of such abnormalitiesTo determine the degree of such abnormalities
i.e. to make a diagnosis, determine the site of thei.e. to make a diagnosis, determine the site of thelesion and formulate a management planlesion and formulate a management plan
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
1.1. BulkBulk
2.2. PowerPower
3.3. ToneTone4.4. Deep Tendon Reflexes (DTRs)Deep Tendon Reflexes (DTRs)
5.5. Abdominal & Plantar reflexesAbdominal & Plantar reflexes
6.6. CoordinationCoordination7.7. GaitGait
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
BULKBULK
IncreasedIncreased
NormalNormal
DecreasedDecreased
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
TONETONE
Hypertonia (increased tone): lead pipe/claspHypertonia (increased tone): lead pipe/clasp
knifeknife Normal toneNormal tone
Hypotonia (flaccidity)Hypotonia (flaccidity)
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
POWER (graded 0 to V)POWER (graded 0 to V)
0 = absent power0 = absent power
I = movement when gravity is eliminatedI = movement when gravity is eliminated II = movement against gravity but not againstII = movement against gravity but not against
the resistance of the examinerthe resistance of the examiner
III = movement against mild resistanceIII = movement against mild resistance
IV = movement against moderate resistanceIV = movement against moderate resistance
V = full powerV = full power
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
DEEP TENDON REFLEXES (DTRs)DEEP TENDON REFLEXES (DTRs)
Hypereflexia (+++)Hypereflexia (+++)
Normoreflexia (++)Normoreflexia (++) Hyporeflexia (+)Hyporeflexia (+)
Areflexia (absent reflex)Areflexia (absent reflex)
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
PLANTAR REFLEXPLANTAR REFLEX
Elicited by stroking the sole of footElicited by stroking the sole of foot
A normal response involves flexion (downwardA normal response involves flexion (downwardmovement) of the great toemovement) of the great toe
Abnormal response involves extension (upwardAbnormal response involves extension (upward
movement of the great toe) +/movement of the great toe) +/-- fanning out offanning out ofthe other toes (Babinski sign)the other toes (Babinski sign)
Abnormal response seen in UMN lesionsAbnormal response seen in UMN lesions
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
ABDOMINAL REFLEX:ABDOMINAL REFLEX:
Elicited by stroking the abdominal wall fromElicited by stroking the abdominal wall from
laterally towards the umbilicus in 4 quadrants.laterally towards the umbilicus in 4 quadrants.1.1. Absent in UMN lesionAbsent in UMN lesion
2.2. Decreased in LMN lesionDecreased in LMN lesion
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
UPPER MOTOR NEURON LESIONSUPPER MOTOR NEURON LESIONS
Seen in lesions (disorders) ofSeen in lesions (disorders) of Brain & Spinal cord:Brain & Spinal cord:
1.1. WeaknessWeakness
2.2. Wasting (mild)Wasting (mild)
3.3. Hypertonia (clasp knife)Hypertonia (clasp knife)
4.4. HypereflexiaHypereflexia
5.5. Babinski signBabinski sign
6.6. ClonusClonus
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
LOWER MOTOR LESIONSLOWER MOTOR LESIONS
Seen in lesions of theSeen in lesions of the peripheralperipheral nerves:nerves:
1.1. Loss of powerLoss of power2.2. Marked muscle wasting (decreased bulk)Marked muscle wasting (decreased bulk)
3.3. HypotoniaHypotonia
4.4. AreflexiaAreflexia5.5. FasciculationsFasciculations
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
Nerve Root Values (Upper Limb Power):Nerve Root Values (Upper Limb Power):
1.1. Shoulder abduction (C5,6)Shoulder abduction (C5,6)
2.2. Shoulder adduction (C5,6,7)Shoulder adduction (C5,6,7)3.3. Elbow flexion (C5,6)Elbow flexion (C5,6)
4.4. Elbow extension (C7,8)Elbow extension (C7,8)
5.5. Wrist flexion (C6,7,8,T1)Wrist flexion (C6,7,8,T1)
6.6. Wrist extension (C6,7,8)Wrist extension (C6,7,8)
7.7. Finger abduction & adduction (C8, T1)Finger abduction & adduction (C8, T1)
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Upper LimbsUpper Limbs
ShoulderShoulderabductionabduction
Deltoid C5/6Deltoid C5/6
Axillary NerveAxillary Nerve
ShoulderShoulderadductionadduction
Pectoralis major C6/7Pectoralis major C6/7
Lattisimus dorsi C7Lattisimus dorsi C7
WristWrist
extensionextension
Extensor carpi radialisExtensor carpi radialis
longuslongus
Extensor carpi ulnarisExtensor carpi ulnaris
C6/7/8C6/7/8
Finger flexion/Finger flexion/Abduction/Abduction/
Adduction/Adduction/ThumbThumbmovementsmovements
Radial/Ulnar/MedianRadial/Ulnar/Median
nerves C8/T1nerves C8/T1
ElbowElbowflexionflexion
Biceps:C5/6Biceps:C5/6
MusculocutaneousMusculocutaneous
nervenerve
ElbowElbowextensionextension
Triceps C7/8Triceps C7/8
Radial nerveRadial nerve
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
DTRs Root Values (Upper Limb)DTRs Root Values (Upper Limb)
1.1. BicepsBiceps -- C5,6C5,6
2.2. SupinatorSupinator -- C5,6C5,63.3. TricepsTriceps C6, 7C6, 7
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
Nerve Root Values (Lower Limb Power):Nerve Root Values (Lower Limb Power):
Hip flexion (L1/2)Hip flexion (L1/2)
Hip extension (L5,S1)Hip extension (L5,S1)
Hip abduction (L4,5,S1)Hip abduction (L4,5,S1)
Hip adduction (L2,3,4)Hip adduction (L2,3,4)
Knee flexion (L5,S1,2)Knee flexion (L5,S1,2)
Knee extension (L2,3,4)Knee extension (L2,3,4)
Ankle (plantar) flexion (S1,2)Ankle (plantar) flexion (S1,2)
Ankle extensionAnkle extension dorsiflexion (L4,5)dorsiflexion (L4,5)
Inversion (L4,5)Inversion (L4,5)
Eversion (L5, S1)Eversion (L5, S1)
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Lower LimbsLower Limbs
Hip flexionHip flexion IliopsoasIliopsoas
L2/3L2/3
FemoralFemoralnervenerve
HipHipextensionextension
GluteiGlutei
L4/5/S1L4/5/S1
GlutealGlutealnervesnerves
HipHip
abductionabduction
Glutei + TensorGlutei + Tensorfascia lata L4/5 S1fascia lata L4/5 S1
HipHip
adductionadduction
AdductorsAdductors
L2/3/4L2/3/4
Obturator nerveObturator nerve
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Lower LimbsLower Limbs
Knee flexionKnee flexion HamstringsHamstringsL5/S1L5/S1
Sciatic nerveSciatic nerve
KneeKneeextensionextension
QuadricepsQuadriceps
L3/4L3/4
Femoral nerveFemoral nerve
AnkleAnkle
dorsiflexiondorsiflexion
Tibialis anteriorTibialis anterior
Extensor hallucisExtensor hallucislonguslongus
L4/5L4/5
Peronial div. ofPeronial div. ofsciatic nervesciatic nerve
AnkleAnkle
plantarplantarflexionflexion
Gastrocnemius,Gastrocnemius,
Tibialis posteriorTibialis posteriorS1S1
Tibial div. ofTibial div. ofsciatic nervesciatic nerve
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
DTRs Root value (lower limb)DTRs Root value (lower limb)
1.1. Knee jerkKnee jerk L2,3,4L2,3,4
2.2. Ankle jerkAnkle jerk -- L5,S1L5,S1
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
Coordination:Coordination:
1.1. FingerFinger--Nose testNose test
2.2. HeelHeel--Shin testShin test
3.3. Rapid alternating movementsRapid alternating movements
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MOTOR SYSTEM EXAMMOTOR SYSTEM EXAM
EXAMINATION OF GAITEXAMINATION OF GAIT
1.1. StationStation
2.2. TurningTurning3.3. TandemTandem
4.4. Heel walkingHeel walking
5.5. Toe walkingToe walking6.6. RhombergsRhombergs