Approach

 to  motor  impairment  

Dr.  Rahul  Kulkarni  

FINE  2014    
Doctor  I  feel  weak!    
 Introduc9on    
•  Weakness  may  be  a  sign  of  a  neurological  condi9on  
•  Many  pa9ents  with  no  neurological  disorder  present  
with  a  complaint  of  weakness  
•  “Weakness”  doesn’t  always  mean  a  true  loss  of  
motor  func9on  
•  Pa9ents  who  are  sick  oHen  complain  of  weakness  
•  Thus,  it  is  cri9cal  that  the  physician  considers  not  
only  the  pa9ent’s  descrip9on  of  the  problem  and  the  
physical  examina9on,  but  also  the  context  in  which  
the  pa9ent  presents  
 Causes  of  ‘apparent’  weakness    
•  Motor  weakness  
•  Fa9gue  
•  Feeling  of  9redness/sleep  disorder  
•  Depression  
•  Numbness  leading  to  motor  dysfunc9on  
•  Incoordina9on  
•  S9ffness  in  Parkinson’s  disease    
 Non-­‐neurological  causes  of  weakness    
•  Cardiac  
•  Conges9ve  cardiac  failure  
•  Low  output  due  to  obstruc9on  
•  Pulmonary  
•  Gas  exchange  failure  
•  Diaphragm  weakness  
•  Systemic    
•  Anemia  
•  Cachexia  in  malignancy  
•  …    
 How  to  rule  them  out?  
•  Proper  history  and  examina9on  
•  If  neurological  examina9on  is  normal,  examine  other  
systems  
Approach  to  motor  weakness    
 Approach:  History      
•  Pa9ent  will  complain  of  weakness    
•  Difficulty  in  doing  certain  ac9vi9es  
•  Depending  on  group  of  muscles  involved,  these  would  vary  
•  Other  important  rou9ne  ques9ons    
•  Mode  of  onset  
•  Associated  features    
•  Past  history        
 Symptoms    
•  Proximal  lower  limb  weakness  
•  Difficulty  in  ge\ng  up  from  chair  
•  Difficulty  in  ge\ng  up  from  floor/toilet  seat  
•  Difficulty  in  ascending  stairs  (gluteal  muscles)  
•  Difficulty  in  descending  stair  (quadriceps)    
•  Distal  lower  limb  weakness  
•  Instability  on  rough  ground  
•  Inability  to  hold  foot  ware  (with  no9ce)  
•  Inability  to  run  (ankle  plantarflexors)  
•  Easy  tripping  (ankle  dorsiflexors)  
 Symptoms  
•  Proximal  upper  limb  weakness  
•  Difficulty  in  combing  hair  
•  Not  able  to  keep/liH  object  from  high  shelf  
•  Difficulty  in  pu\ng  shirt    
•  Distal  upper  limb  weakness    
•  Difficulty  in  buaoning  and  unbuaoning  
•  Difficulty  while  ea9ng  
•  Deteriora9on  in  hand  wri9ng  
•  Difficulty  in  opening  door    
 Symptoms  
•  Trunkal  weakness  
•  Difficulty  in  ge\ng  up  from  lying  posi9on  
•  Difficulty  in  turning  in  bed  
•  Neck  weakness  
•  Difficulty  to  liH  neck  while  ge\ng  up  from  supine  posi9on  
•  Difficulty  in  holding  neck  while  bending  forward/si\ng  
•  Bulbar  weakness  
•  Difficulty  in  swallowing  (liquid>solid)  
•  Change  in  speech    
•  Difficulty  in  chewing      
 Approach:  History    
•  Other  clues    
•  Apart  from  weakness,  pa9ent  can  have  addi9onal  symptoms    
•  Fa9gability    
•  Symptoms  vary;  beaer  in  morning  and  worsens  by  evening  
•  Difficulty  in  climbing  last  steps  of  stair  
•  Difficulty  in  chewing  last  por9on  of  meal    
•  Heaviness  
•  Limbs  feel  s9ff  and  heavy  
•  Legs  cross  each  other  while  walking  
•  Get  jerks  in  legs  while  lying  flat      
 Approach:  examina9on    
•  One  should  follow  fixed  protocol  
•  Can  vary  from  person  to  person  
•  Do  not  violet  it  
•  Maximum  mistakes  are  done  when  you  use  short  
cuts    
 CNS  examina9on    
•  Higher  func9on/Cranial  nerves  
•  Motor  examina9on  
•  Nutri9on  
•  Tone  
•  Power  
•  Coordina9on  
•  Involuntary  movements  
•  Reflexes  
•  Sensory  examina9on    
•  Gait    
 Strength/power    

MRC  grading  of  power  

•   Grade  0:  no  movement  
•   Grade  I:  visible  muscle  flicker  
•   Grade  II:  movement,  but  not  against  gravity      
•   Grade  III:  movement  against  gravity  
•   Grade  IV:  movement  against  some  resistance  
•   Grade  V:  normal      
 Examina9on  of  power  
•  Simple  9ps  to  check  strength  
•  Try  to  keep  muscle  to  be  examined  uncovered    
•  During  examina9on  try  to  keep  one  hand  on  muscle  to  be  
tested  and  other  hand  to  apply  resistance  
•  While  applying  resistance,  keep  hand  near  inser9on  of  
muscle  
•  If  possible,  check  muscles  on  both  side  simultaneously  
•  If  subtle  weakness  is  present,  it  may  be  missed  in  rou9ne  
examina9on  
•  Pronator  driH  
•  Gait  assessment        
 Case  
•  Pa9ent  complaining  of  weakness  of  leH  UL  and  pain  
near  shoulder  since  1  year  
•  Rou9ne  examina9on  is  all  normal  

•  Examina9on  aHer  stripping    

•  Was9ng  of  infrascapular    
         muscle  
•  Weakness  of  spina9    
 Tone    
•  Tone  should  be  examined  in  relaxed  posi9on    
•  Some  pa9ents  can  never  ‘relax’  
•  In  them  tone  examina9on  is  difficult  
•  Various  methods  to  check  tone  
•  At  rest  
•  During  passive  movement  
 Tone    
•  Reduced  muscle  tone  is  hard  to  detect  unless  severe  
•  Don’t  worry  about  it  
•  Increased  tone  is  much  more  important  
•  Two  main  types  
•  Spas9city  (pyramidal)  
•  Rigidity  (extrapyramidal)  
 Coordina9on    
•  In  a  pa9ent  with  weakness,  coordina9on  is  difficult  
to  assess  
•  Two  main  types  of  ataxia:  
•  Motor/cerebellar  ataxia  
•  Sensory  ataxia  
 Cerebellar  ataxia    
•  Stacato  or  scanning  speech  
•  Nystagmus  
•  Beats  away  from  midline  
•  Gaze  evoked  
•  Inten9onal  tremors  
•  FNF  and  HKH  ataxia  
•  Broad  based  gait    
•  Reflexes  are  normal    
 Sensory  ataxia    
•  Usually  have  sensory  symptoms  in  lower  limbs  
•  Ataxia  worsens  when  visual  clue  is  removed  
•  Even  cerebellar  ataxias  do  so!  
•  At  night  
•  While  washing  face      
•  Pseudoathetosis  in  upper  limb  
•  Posi9ve  Rhomberg’s  sign  
•  Reflexes  may  be  depressed  in  LL  
•  Loss  of  joint,  posi9on  and  vibra9on  sense    
 Sensory  ataxia  
•  Due  to  impairment  of  propricep9ve  pathways  
•  Posterior  column  
•  B12  deficiency  
•  Mul9ple  sclerosis    
•  Dorsal  root  ganglion  
•  Sjogren  syndrome  
•  Paraneoplas9c    
•  Large  fiber  nerves  
•  CIDP  
•  Diabetes  
 Cerebellar  vs.  sensory  ataxia    
Cerebellar  ataxia     Sensory  ataxia    
Ataxia  while  walking   +   +  
Worsening  at  night   +   ++  
Limb  ataxia   ++   +/-­‐  
Dysarthria   +   -­‐  
Nystagmus   +   -­‐  
Sensory  symptoms  in  LL   -­‐   +  
Reflexes   Pendular   Depressed  
Propricep9on   Normal   Impaired  
 Reflexes    

MRC  grading  of  reflexes  

•   -­‐  Absent  
•   -­‐/+  Present  with  reinforcement  
•   +  Depressed    
•   ++  Normal  
•   +++  Brisk  
•   ++++  Clonus    
 Reflexes    
•  Classically  brisk  in  UMN  lesion  and  depressed  or  
absent  in  LMN  lesion  
•  In  acute  UMN  lesion  (spinal  or  neuronal  shock),  
reflexes  are  absent  
•  In  certain  LMN  diseases  reflexes  are  well  elicited  
(look  like  brisk  at  9mes)  
•  Myasthenia  gravis  
•  Osteomalacic  myopathy  
•  Polymyosi9s  
•  Thyrotoxicosis    
 Sensa9on    
•  Most  unreliable  of  all  test  
•  Completely  subjec9ve  
•  Difficult  for  pa9ent  as  well!  
•  Try  to  do  in  at  end  
•  Tailor  the  sensory  examina9on  aHer  clues  from    
history  and  motor  examina9on    
•  In  order  to  perform  a  meaningful  sensory  
examina9on,  you  need  to  know  what  paaern  of  
sensory  loss  you  are  looking  for!    
 Gait    
•  Important  part  of  motor  assessment  
•  Usually  ask  pa9ent  to      
•  Walk  normally  
•  Walk  on  toes  
•  Walk  on  heel  
•  Walk  on  straight  line  (tandem  gait)    
 Gait    
•  Some  common  abnormal  gaits  
•  Hemipare9c  (circumduc9on)  
•  Spas9c  (scissor)  
•  Parkinsonian  (fes9na9ng)  
•  Foot  drop  (high  stepping)  
•  Ataxic  (broad  based)  
•  Waddling  (myopathic)  
 Other  signs    
•  Involuntary  movements  
•  Fascicula9ons  
•  Flexor  spasms  
•  Tremors  
•  Others      
•  Spine  examina9on  
•  Kyphosis  
•  Local  tenderness  
•  Foot  examina9on  
•  Pes  cavus  
 Approach:  examina9on    
•  At  the  end  of  examina9on  one  can  decide  
•  LMN  vs.UMN  lesion  

LMN  
UMN   •   Lesion  of  anterior  horn  cells  
•   Lesion  of  brain  
•   Lesion  of  roots    
•   Lesion  of  spinal  cord  
•   Lesion  of  nerves  
•   Lesion  of  NM  junc9on  
•   Lesion  of  muscle    
 UMN  vs.  LMN    
UMN   LMN  
Tone   Increased  (spas9city)   Normal  or  reduced  
Extensors  in  UL     Muscles  supplied  
Weakness  
Flexors  in  LL   by  affected  LMN  
Was9ng     No  →  disuse   No  →  severe  
Reflexes   Brisk     Depressed/absent  
Plantar  reflexes   Extensor   Flexor    
Involuntary   Flexor  spasms   Fascicula9ons  +/-­‐  
movements  
 Acute  UMN  vs.  LMN  
Acute  UMN   Acute  LMN  
Tone   Reduced   Reduced  
Weakness   En9re  extremity/ies   En9re  extremity/ies  
Was9ng     No   No  
Reflexes   Depressed/absent   Depressed/absent  
Plantar  reflexes   Mute/Extensor   Mute/Flexor    
Involuntary   Nil   Nil  
movements  
Bladder  involvement   ++   -­‐  
Sensory  impairment   ‘Level’  over  trunk     Glove  and  stocking  
 Brain    
•  Unilateral  weakness  
•  Monoplegia  is  more  oHen  due  to  brain  than  spinal  cord  
lesion  
•  Rarely  bilateral  signs  
•  Flaccid  in  acute  stage  (neuronal  shock)  
•  Bladder  involvement  is  uncommon    
•  Associated  cranial/higher  func9on  impairment  
 Spinal  cord    
•  Bilateral  signs  
•  Many  9mes  asymmetric  
•  May  have  symptoms  in  glove  and  stocking  distribu9on  
•  Flaccid  in  acute  stage  (spinal  shock)  
•  Recovers  over  9me  
•  Usually  with  reten9on  of  urine  
•  Involves  extensor  muscles  in  UL  and  flexor  in  LL  
•  Triceps  and  grip  in  UL  
•  Hip  flexors  in  LL  
•  Sensory  may  be  unreliable  in  long  standing  cases    
 Anterior  horn  cell  
•  Pure  motor  
•  Marked  was9ng  
•  Patchy  weakness  
•  Proximal  
•  Distal  
•  Asymmetric    
•  Reflexes  are  depressed  
•  Fascicula9on  may  be  widespread  
•  Progressive  (MND)  or  nonprogressive  (polio)      
 Root    
•  Radiculopathies  are  painful  
•  Root  pain  
•  Neck/back  pain  
•  Sensory  loss/symptom  in  dermatomal  fashion  
•  Motor  weakness  is  segmental  
•  Triceps  in  UL  
•  EHL  in  LL    
 Nerve    
•  Widespread  sensory  symptoms>motor  
•  Distal  disease    
•  Glove  and  stocking  symptoms  
•  Distal  was9ng  in  long  standing  cases  
•  Reflex  loss  is  out  of  propor9on  than  weakness  
•  Rare  
•  Proximal  
•  Asymmetric  
•  Pure  motor    
 NM  junc9on    
•  Proximal>distal  
•  Ocular  
•  Bulbar  
•  Neck/trunk    
•  Proximal  limbs  
•  Pure  motor  
•  Fa9gability  
•  In  early  stage  there  may  not  be  any  signs!  
 Muscle    
•  Pure  motor  
•  Proximal>distal  
•  Par9cular  group  of  muscles  are  more  involved    
•  Less  was9ng  
•  At  9mes  ‘pseudo’hypertrophy    
•  Reflexes  are  lost  ‘late’  
 LMN  weakness    
NM  
AHC   Nerve   Muscle  
juncBon  
Was9ng     ++   +   -­‐   +/-­‐  
Hypertrophy   -­‐   -­‐   -­‐   +/-­‐  
Weakness   Proximal   Distal   Proximal   Proximal  
Bulbar   Uncommo -­‐   Common   Rare    
n    
Reflexes   Lost   Lost  early   Normal   Lost  late    
Sensory   -­‐   ++   -­‐   -­‐  
Fascicula9on ++   +   -­‐   -­‐  
s  
Paaerns  of  weakness    
 Asymmetric  UMN  
•  Brain  
•  Hallmark  is  unilateral  features        
•  Stroke  
•  Demyelina9on  
•  Others  
•  Spinal  cord    
•  Rare  to  have  strictly  unilateral  involvement    
•  Usually  will  have  some  signs  on  other  side      
 Symmetric  UMN  
•  Spinal  cord  
•  Compressive  
•  Myeli9s/demyelina9on  
•  Others    
•  Brain  
•  Very  rare  to  get  symmetrical  signs    
 Symmetric  proximal  LMN  
•  Common  
•  Myopathy  
•  Anterior  horn  cell  diseases  
•  Uncommon  
•  Demyelina9ng  neuropathy  
 Symmetric  distal  LMN  
•  Common    
•  Polyneuropathy  
•  Rare  
•  Distal  myopathy  
•  Anterior  horn  cell  disease  
 Asymmetric  LMN  
•  Common  
•  Polio  
•  Plexopathy  
•  Polyradiculopathy    
Other  causes    
 Extrapyramidal    
•  The  hallmark  is  ‘slowness’  (bradykinesia)  
•  Motor  power  is  actually  normal  
•  Pa9ent  takes  longer  to  exert  and  appears  weak  if  
examined  in  hurry  
•  Other  signs    
•  Rigidity  
•  Tremors    
•  Normal  reflexes  
•  Flexor  plantars      
 Pyramidal  vs.  extrpyramidal    
Pyramidal   Extra-­‐pyramidal  
Tone     Spas9city   Rigidity  
Power   Weakness  ++   Normal  
Reflexes   Brisk   Normal  
Plantar  reflex   Extensor   Flexor  
Asymmetry   +   +  
Sensory   Symptoms  and  signs   Symptoms  
Slowness   +   ++  
 Parkinson’s  disease    
•  Early  symptoms  are  nonspecific  
•  OHen  missed  
•  Frozen  shoulder  
•  Cervical  spondylosis  
•  Depression  
•  ‘Hypothyroidism’  with  normal  TFTs!    
•  Look  for  subtle  signs  
•  Loss  of  associated  movements  while  walking  
•  Facial  expressions  
•  Mild  rigidity    
 Fa9gue    
•  Fa9gue  can  be  a  feature  of  many  motor  disorders  
•  Parkinson’s  disease  
•  Mul9ple  sclerosis  
•  Neurological  fa9gue  classically  occurs  in  myasthenia  
•  However  fa9gue  also  is  a  feature  of    
•  Medical  diseases          
•  Depression  
•  Chronic  fa9gue  syndrome  
•  In  these  pa9ents,  the  neurological  examina9on  will  
be  normal    
 Carry  home  messages…  
•  Weakness  encompass  many  diseases  
•  Try  to  dissect  them  out  from  history  
•  Examine  with  your  own  protocol  
•  Do  not  use  short  cuts  
•  Pronator  driH  and  gait  examina9on  are  important  signs    
•  Sensory  signs  at  9mes  are  confusing  
•  They  are  subjec9ve  
•  Myasthenia  and  Parkinson’s  disease  will  present  
without  any  signs  at  9mes  
•  Need  high  degree  of  suspicion