Upper Neurological Motor Examination
Both motor examinations follow the same general sequence making them easier to remember. However, there is a lot of steps, so you may want to use this acronym to make sure you don't skip one...
Observation Tone Power Reflexes Co-ordination
Observe The Patient Really Carefully
As with all the examinations, begin with the same opening sequence. Being friendly and rewording questions to make them sound less rehearsed will make your bedside manner appear much more natural and confident.
- Wash hands
- Introduce yourself
- Confirm their name, age and date of birth (try and remember the first 2 for your closing summary!)
- Consent eg. I've been asked to do a motor examination of your upper limbs today which will involve having a look, feel and move around of your arms - is that alright with you? - Again, rephrase to what you feel most natural saying.
- Check for pain or problems in movement
- Expose the patient appropriately (remove shirt for upper motor examination)
The patient should be appropriately exposed and at 45 degrees on the bed.
Also you may want to comment on whether the patient looks unwell or in obvious pain or distress.
I'm now going to test the tone of your arms, so can you please give me the entire weight of your arm and just relax. Hold their hand as if shaking it, and put your other hand under their elbow to stabilise the arm. Then move all the joints making sure to cover the wrist, elbow and shoulder.
- HYPOTONIA - reduced tone (floppier than you'd expect)
- HYPERTONIA - increased tone (spasticity and rigidity)
Comment on any abnormalities, or state that the tone in both arms is normal and equal.
There are two steps to testing power, firstly assessing active movement of the patient and subsequently the same movements against resistance. By doing single movements in turn on each arm means you can directly compare the results.
- Extension/Abduction/Opposition (try to pull a finger-thumb ring apart).
You can either summarise by simply stating the power in both limbs is normal and equal, or for extra marks grade the power out of 5 on the MRC scale (see end).
Reflexes are tested using a tendon hammer, it's the main stage of this examination to practice before an exam to make sure you know exactly where the tendon should be hit.
I'm now going to test your reflexes by tapping on parts of your arm with this hammer, is that alright? Can you completely relax for me please?
Making sure that the patient is relaxed and comfortable will make the reflexes much easier to find. Do all reflexes on both sides to check for symmetry, and comment on their strength. In upper limbs examinations especially, it is often a flicker of movement that you will experience rather than a more exaggerated jerk. If in an exam you can't find a reflex then don't worry - they can be pretty hard to find! Just try a couple of times and then ask the patient to reinforce the reflex by clenching their teeth. If you still can't find it then don't panic and move on, there will be marks for attempting the reflex and getting the technique right.
- BICEPS JERK - tapping the biceps tendon on the forearm, near to where you'd take blood. If the tendon is not obvious then ask the patient to flex their arm so you can locate it's position.
- TRICEPS JERK - tapping the triceps tendon just above the elbow on the back of the arm.
- SUPINATOR JERK - ask the patient to relax their arm across their body and tap a little above their wrist on the supinator tendon.
There are two tests of coordination that are to be done in the upper limb examination which both need to be explained really clearly as to avoid confusion. Remember to do both tests with both arms.
- FINGER-NOSE TEST - ask the patient to touch their nose and then your finger which you hold just within their reach. Change the position of your finger as it goes along and encourage them to keep touching between nose and finger.
- RAPID ALTERNATING MOVEMENTS - demonstrate turning one hand over and over in the palm of the other, slowly increasing speed. If they can't perform this rapidly then this is described as dysdiadochokinesia.
As always, end your examination by thanking the patient, allowing them to cover themselves up, and washing your hands.
SUMMARY - as at the end of every examination you will be asked to summarise your findings. Begin with their name and age, and then briefly comment on each section before finishing with an overall statement such as this was a normal upper motor examination.
Power is scored out of 5: 0: No movement 1: Flicker of contraction 2: Movement, but not against gravity 3: Movement against gravity, but without resistance 4: Decreased movement against resistance 5: Normal When recording Motor tone, +/- is sometimes used: +++ = Hypertonia ++ = Normal + = Hypotonia - = Absent Try to stay away from this when possible though, as it's confusing to readers.