Faculty of Medicine Siriraj Hospital Mahidol University

Neurological Society of Thailand

Approach to Weakness Naraporn Prayoonwiwat, M.D. Neurology Division, Department of Medicine Siriraj Hospital

[email protected] 02 419 7101-2 Neurologic Evaluation Weakness  Clinical data gathering History Physical examination: motor system: tone/power; sensory system  Interpretation, localization Upper versus lower Motor pathway: cortex to muscle d NP Neurologic Evaluation General Concepts  Clinical data gathering History ✔︎Chief complaint: clearly defined Present illness: as much as possible ✔︎- Quality of symptoms - Location distinctive features e.g. character, severity, etc. ✔︎- Time course onset: abrupt or insidious subsequent course: improving, d NP worsening, exacerbation-remission Neurologic Evaluation General Concepts Sudden: Progressive:Clinical data gathering - stroke - tumor History - trauma - degenerative ✔Chief complaint: clearly defined Present illness: as much as possible Paroxysmal: Relapsing-remitting: ✔ --epilepsyQuality of symptoms- multiple sclerosis --syncopeLocation distinctive- neuromyelitis features optica e.g. - periodic paralysis character, severity, etc. ✔--transientTime course ischemic attackonset: abrupt or insidious subsequent course: improving, d NP worsening, exacerbation-remission Neurologic Evaluation General Concepts  Clinical data gathering History e.g.: exertion (fatigue) Present illness: ✔︎- Factors precipitating/aggravating/ alleviating symptoms systemic ✔︎- Associated symptoms neurologic

d NP Neurologic Evaluation General Concepts  Clinical data gathering History Past medical history: - illnesses - operations - medication ✔︎- immunization Diet, tobacco, alcohol, substance abuse

d NP Neurologic Evaluation General Concepts  ClinicalVaccine data: protective gathering against organisms Historycausing neurologic disorders (e.g. Past poliovirus,medical history: tetanus, rabies virus, - illnessesJapanese encephalitis- operations virus, - medicationmeningococcal,✔︎- immunizationpneumococcal, Diet, Hemophilustobacco, alcohol,influenzae substance abuse Post vaccination: immunological reactions i.e. ADEM (Acute Disseminated EncephaloMyelitis d NP Neurologic Evaluation General Concepts  Clinical data gathering Family history: First degree relatives: parents, siblings, children Second degree relatives: grandparents, grandchildren Social history: education, occupation

d NP Neurologic Evaluation General Concepts  Physical examination Mental status ✔︎ Cranial nerves ✔︎ Motor function ✔︎ Sensory function Coordination Gait and stance

d NP Neurologic Evaluation Weakness  Inspection  Muscle tone: tension of a muscle at rest  examination  interpretation  Muscle power  examination  grading system  interpretation

d NP Neurologic Evaluation Weakness ✔︎  Inspection - Compare both sides  Muscle tone:- tensionLook for of muscle a muscle atrophy, at rest asymmetry  examination  interpretation  Muscle power  examination  grading system  interpretation

d NP Neurologic Evaluation Weakness  Inspection ✔︎  Muscle tone: tension of a muscle at rest  examination  interpretation  Muscle power  examination  grading system  interpretation

d NP -NeurologicCompare both Evaluation sides - AlwaysWeakness check for tone i.e.  Inspectionresistance to passive movement (muscles relaxed)  Muscle tone: tension of a muscle at rest ✔︎ -Tone:Avoid exertupper pressure limbs directly  examinationupon muscles  interpretation- hold one hand in the “shake hands” position  Muscle power  examination- support at the elbow  grading systemelbow flex/extend  interpretationforearm supinate/pronate - hold forearm above the wrist wrist flex/extend d NP -NeurologicCompare both Evaluation sides - AlwaysWeakness check for tone, i.e.  Inspectionresistance to passive movement (muscles relaxed)  Muscle tone: tension of a muscle at rest ✔︎ -Tone:Avoid lowerexert limbspressure directly  examinationupon muscles  interpretationhand on knee, “roll” each knee from side to side  Muscle power hands under knee, “snap”  examination lifting, observe the heel  grading system  interpretation

d NP Neurologic Evaluation Weakness  Inspection  Muscle tone: tension of a muscle at rest  examinationTone: ✔︎ interpretationHypotonia >> flaccid  Muscle powerNormotonia  examinationHypertonia: spasticity, rigidity  grading system  interpretation

d NP Neurologic Evaluation Weakness  Inspection  Muscle tone: tension of a muscle at rest  examination  interpretation  Muscle power ✔︎ examination  grading system  interpretation

d NP Upper limbNeurologic Evaluation Shoulder DeltoidWeakness (abduction) ElbowInspectionBiceps (flexion)  Muscle tone:Brachioradialis tension of a(flexion) muscle at rest  examinationTriceps (extension) Radio interpretation- Pronator ulnar Supinator  Muscle power ✔︎Wrist Flexor  examinationExtensor Finger grading Handgripsystem (flexion)  interpretationExtensor Dorsal interossei (adduction) Palmar interossei (abduction) d NP Upper limbNeurologic Evaluation Weakness -ShoulderDeltoid: ExertDeltoid pressure (abduction) close to ElbowInspectionelbow Biceps (flexion) -MuscleBiceps: tone:PlaceBrachioradialis tension one hand of aat(flexion) muscle patient at’s rest  examinationshoulderTriceps to stabilize (extension) -RadioTriceps:interpretation- TestPronator with arm extended is ulnar Supinator  Muscleless painful power than with arm flexed ✔︎Wrist Flexor  examinationExtensor Finger grading Handgripsystem (flexion)  interpretationExtensor Dorsal interossei (adduction) Palmar interossei (abduction) d NP Neurologic Evaluation Weakness MRC  Muscle power  examination  grading system  interpretation

Triceps

Extend elbow Elbow extension against resistance d NP Upper limbNeurologic Evaluation Weakness -ShoulderDeltoid: ExertDeltoid pressure (abduction) close to ElbowInspectionelbow Biceps (flexion) -MuscleBiceps: tone:PlaceBrachioradialis tension one hand of aat(flexion) muscle patient at’s rest  examinationshoulderTriceps to stabilize (extension) -RadioTriceps:interpretation- TestPronator with arm extended is ulnar Supinator  Muscleless painful power than with arm flexed ✔︎-WristPronatorFlexor sign to detect mild weakness  examinationExtensor Finger grading Handgripsystem (flexion)  interpretationExtensor Dorsal interossei (adduction) Palmar interossei (abduction) d NP Upper limbNeurologic Evaluation Weakness -ShoulderDeltoid: ExertDeltoidPronator pressure (abduction) sign close to Position:ElbowInspectionelbow Biceps (flexion) --MuscleraiseBiceps: both tone:PlaceBrachioradialis arms tension one forward hand of aat(flexion) muscle patient at’s rest -fullyexaminationshoulder extendTriceps to andstabilize (extension)supinate both arms --RadiofullyTriceps:interpretation -extend TestPronator and with abduct arm extended fingers is ulnar Supinator -Musclecloseless painfulthe power eyes than with arm flexed -WristPronatorFlexor sign to detect mild weakness Interpretation:✔︎ examination test positive if - arm driftExtensor down  grading system Minimal arm -Fingerelbow flexHandgrip (flexion)  interpretation weakness - forearm pronateExtensor - wrist andDorsal fingers interossei flex (adduction) Palmar interossei (abduction) d NP Lower limbNeurologic Evaluation Hip GluteusWeakness maximus (extension)  InspectionIliopsoas (flexion)  Muscle tone:Adductor tension of a muscle at rest  examinationAbductor Knee interpretationQuadriceps (extension) Hamstring (flexion)  Muscle power ✔︎Ankle Gastrosolieus (extension)  examinationTibialis anterior (flexion)  gradingTibialis system posterior (inversion)  interpretationPeroneii (eversion) Toe Flexor Extensor d NP Lower limbNeurologic Evaluation Hip GluteusWeakness maximus (extension)  InspectionIliopsoas (flexion)  MuscleHints: tone:Adductor tension of a muscle at rest -examinationAvoid Abductorpressing on the thigh Knee-interpretationUse theQuadriceps knee as pressure (extension) point Hamstring (flexion)  Muscle power ✔︎Ankle Gastrosolieus (extension)  examinationTibialis anterior (flexion)  gradingTibialis system posterior (inversion)  interpretationPeroneii (eversion) Toe Flexor Extensor d NP Neurologic Evaluation Weakness Grade Character  Inspection 0 No movement  Muscle tone: tension of a muscle at rest 1 Minimal movement  examination 2 Horizontal movement  interpretation3 Against gravity, unsustain  Muscle4 powerAgainst resistance, partial  examination5 Against resistance, strong (normal) ✔︎ grading system Gradinginterpretation system: Medical Research Council (MRC); UK

d NP Neurologic Evaluation Weakness  Inspection  Muscle tone: tension of a muscle at rest  examination  interpretation  Muscle power  examination  grading system ✔︎ interpretation

d NP Neurologic Evaluation Weakness Patterns of weakness  Inspection - pyramidal weakness  Muscle- proximal tone: weakness tension of a muscle at rest Pyramidal weakness: - examinationdistal weakness upper limb: flexor group stronger -interpretationspecific pattern “decorticate posture”  Musclelower limb: powerextensor group stronger  examination: (UMN)  grading: corticospinal system tract lesion ✔︎ interpretation

d NP Neurologic Evaluation Weakness Patterns of weakness  Inspection - pyramidal weakness  Muscle- proximal tone: weakness tension of a muscle at rest - examinationdistal weakness Proximal weakness: -interpretationspecific pattern more weakness of proximal group  Muscle(arms power and legs)  examination: muscle disease e.g.  gradingmetabolic system myopathy ✔︎ interpretationmyositis : neuromuscular junction d NP Neurologic Evaluation Weakness Patterns of weakness  Inspection - pyramidal weakness  Muscle- proximal tone: weakness tension of a muscle at rest - examinationdistal weakness  interpretation Distal- specific weakness: pattern  Musclemore weakness power of distal group,  examinationmuscle wasting may be present  grading: peripheral system nerve e.g. ✔︎ interpretationdistal symmetrical polyneuropathy

d NP Neurologic Evaluation Weakness Patterns of weakness  Inspection - pyramidal weakness  Muscle- proximal tone: weakness tension of a muscle at rest - examinationdistal weakness -Specificinterpretationspecific pattern: pattern  Muscleweakness/wasting power according to :examination peripheral nerve distribution :grading brachial, system lumbosacral plexus ✔︎:interpretation spinal nerve roots : cauda equina : muscular dystrophy d NP Neurologic Evaluation General Concepts  Physical examination MentalProcedure status Cranial- optimum nerves posture Motor- symmetry function for ✔︎ Reflexescomparison Sensory- relaxed function posture Coordination- brisk and strong

Gaitpercussion and stance Jerk hammer - observe the responses d NP Muscle  Tools  Procedure (C5-6) Brachioradialis (C5-6) Triceps reflex (C7-8)  Interpretation/recordingMusculocutaneous Radial nerve Radial nerve  Abnormality

Quadriceps reflex (L2-3) Ankle reflex (S1-2) d NP. NiceFemoral nerve Tibial nerve illustration:Tibial Songkram nerveChotik-anuchit, MD Neurological Examination Muscle Stretch Reflex

ReflexReflex spreading: arc UMNToolslesion above level of the muscle to which reflexProcedure spreads, e.g. hip adductionInterpretation/recording with knee jerkAbnormality

Quadriceps reflex (L2-3) Femoral nerve d NP. Nice illustration: Songkram Chotik-anuchit, MD Neurological Examination Superficial Reflex  Reflex arc  Tools  Procedure  Interpretation/recording  Abnormality

Normal: Plantar flexion of big toe Abnormal: DorsiflexionPlantar reflex of big toe d NP. Nice Tibial nerve illustration: Songkram Chotik-anuchit, MD Neurological Evaluation Muscle Stretch Reflex Interpretation (grading)

Grading Interpretation 0 absent 1+ or + diminished 2+ or ++ normal 3+ or +++ brisk 4+ or ++++ brisk with clonus

 NP Neurological Examination Muscle Stretch Reflex  Signs associated with corticospinal tract lesion - Clonus - Grasp reflex - Tromner sign - Babinski sign Tromner sign Flick the hyperextended middle finger results in flexion of other fingers d NP Neurologic Evaluation Weakness  Muscle power  examination  grading system  interpretation: localize the lesion UMN versus LMN versus non neurogenic

UMN: upper motor neuron from motor cortex > corona radiata (corticobulbar/corticospinal tracts) > posterior limb of internal capsule > brainstem > spinal cord (corticospinal tract) LMN: from anterior horn cell > ventral rami of spinal nerve > brachial/lumbosacral plexus > peripheral nerve NMJ: neuromuscular junction d NP Neurological Evaluation Cortical Motor System Sub cortical

LMN Brain stem Anterior horn cell

Spinal nerve Spinal cord Nerve plexus

Peripheral nerve UMN Neuromuscular junction Non neurogenic d NP Muscle Neurologic Evaluation Weakness  Muscle power  examination  grading system  interpretation: localize the lesion UMN versus LMN versus non neurogenic

UMN: upper motor neuron from motor cortex > corona radiata (corticobulbar/corticospinal tracts) > posterior limb of internal capsule > brainstem > spinal cord (corticospinal tract) LMN: lower motor neuron from anterior horn cell > ventral rami of spinal nerve > brachial/lumbosacral plexus > peripheral nerve NMJ: neuromuscular junction d NP Neurologic Evaluation Weakness  Muscle power  examinationUpper motor Lower motor Type/Parameters  grading systemneuron neuron Tone Increase* Decrease  interpretation: UMN versus LMN Atrophy Uncommon Prominent Localize the lesion Fasciculation Absent Present UMN: upper motor neuron from motor cortex > corona radiata Hyporeflexia/ Deep(corticobulbar/corticospinal Hyperreflexia tracts) > posterior* limb of internal capsule > brainstem > spinal cord (corticospinal tract)Areflexia LMN: lower motor neuron from anterior horn cell > ventral rami Plantar reflex Extensor Flexor of spinal nerve > brachial/lumbosacral plexus > peripheral nerve NMJ:*Acute neuromuscular phase: hypotonia junction ; hyporeflexia/areflexia d NP Neurologic Evaluation Weakness Localization Cerebral Brainstem Spinal cord Parameter Musclehemisphere power Distribution Contralateral leg Contralateral leg Ipsilateral leg and of muscles examination and arm, cranial and arm, cranial arm, specific group involved gradingmuscles systemnerve involvement (segmental) Type UMN UMN LMN and UMN* When involve Atrophy interpretation:Absent or mild localizeAbsent or mild the lesion anterior horn cell TendonUMN reflexversus LMN versus non neurogenic Plantar reflex Extensor Extensor Extensor Sensory When involve When involve When involve STT, symptoms sensory cortex sensory tract posterior column Tumor, motor Myelitis, Example neuron disease, Stroke Syringomyelia stroke

UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Cortical lobe signsNeurologic Evaluation Language (dominant hemisphere) Gaze deviation (frontalWeakness eye field) CorticalLocalization sensationCerebral  Muscle power Brainstem Spinal cord ApraxiaParameterParameter hemisphere Cortical hemisphere Distribution Contralateral leg Contralateral leg Ipsilateral leg and ofDistribution muscles examination and of arm, cranialContralateral and arm, cranial cranial arm,muscles, specificarm group involvedmuscles grading muscles systemand leg;nerve corticalinvolvement lobe (segmental) signs TypeType UMN UMN UMN LMN and UMN* When involve Atrophy interpretation:Absent or mild localizeAbsent or mild the lesion Atrophy Absent or mild anterior horn cell TendonTendonUMN reflexversus reflex LMN Increased versus non neurogenic Plantar reflex Extensor Extensor Extensor Plantar reflex Extensor Sensory When involve When involve When involve STT, symptomsSensory symptomssensory cortexPresentsensory if involve tract sensoryposterior cortex column Tumor, motor Additional deficits Gaze deviation, motorMyelitis, aphasia Example neuron disease, Stroke Syringomyelia stroke (in dominant hemisphere) Example Tumor, hemispheric infarction, UMN: upper motor neuron; LMN: lower motor neuron d NP STT:motor spinothalamic neuron tract; disease MND: motor neuron disease Neurologic Evaluation Weakness Localization Cerebral Muscle power Brainstem Spinal cord ParameterParameter hemisphere Subcortical Distribution Contralateral leg Contralateral leg Ipsilateral leg and ofDistribution muscles examination and of arm, cranialContralateral and arm, cranial cranial arm,muscles, specific armgroup involvedmuscles grading muscles systemand nerveleg (severity involvement leg (segmental) = arm) TypeType UMN UMN UMN LMN and UMN* When involve Atrophy interpretation:Absent or mild localizeAbsent or mild the lesion Atrophy Absent or mild anterior horn cell TendonUMNTendon reflexversus reflex LMN Increased versus non neurogenic Plantar reflex Extensor Extensor Extensor Plantar reflex Extensor Sensory When involve When involve When involve STT, symptomsSensory symptomssensory cortexPresentsensory if involve tract thalamusposterior column Tumor, motor Additional deficits Myelitis, Example neuron disease, Stroke Syringomyelia Example stroke Lacunar infarction

UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Cranial nerveNeurologic Evaluation Mid brain: CN III, IV Weakness Pons: CN V, VI, VII, VIII Localization Cerebral Medulla:Muscle CN IX, power X, XI, XII Brainstem Spinal cord ParameterParameter hemisphere Brain stem Distribution Contralateral leg Contralateral leg Ipsilateral leg and ofDistribution muscles examination and of arm, cranialContralateral and arm, cranial leg and arm, arm, specific cranial group involvedmuscles grading muscles systemnervenerve involvement involvement (segmental) TypeType UMN UMN UMN LMN and UMN* When involve Atrophy interpretation:Absent or mild localizeAbsent or mild the lesion Atrophy Absent or mild anterior horn cell TendonUMNTendon reflexversus reflex LMN Increased versus non neurogenic Plantar reflex Extensor Extensor Extensor Plantar reflex Extensor Sensory When involve When involve When involve STT, symptomsSensory symptomssensory cortexPresentsensory if involve tract sensoryposterior tract column Tumor, motor Additional deficits CN involvement Myelitis, Example neuron disease, Stroke Syringomyelia Example stroke Brainstem infarction

UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Sensory Neurologic Evaluation - vibratory, joint positionWeakness ipsilateral - pinprick, touch contralateral Localization Cerebral  Muscle power Brainstem Spinal cord ANS:ParameterParameter bowel, bladder,hemisphere sweating Spinal cord Distribution Contralateral leg Contralateral leg Ipsilateral leg and ofDistribution muscles examination and of arm, cranialipsilateral and arm,leg cranial and arm,arm, specific specific group involvedmuscles grading muscles systemmusclenerve group involvement (segmental) (segmental) TypeType UMN LMN (at theUMN level)+ UMNLMN (below)* and UMN* When involve Atrophy interpretation:Absent or mild localizeAbsent or mild the lesion Muscle pain/ absent anterior horn cell TendonUMNtenderness reflexversus LMN versus non neurogenic PlantarAtrophy reflex Extensorpresent ifExtensor involve anteriorExtensor horn cell SensoryTendon reflexWhen involveincreased When involve(below) When involve STT, symptoms sensory cortex sensory tract posterior column Plantar reflexTumor, motorextensor Myelitis, Example neuron disease, Stroke Sensory symptoms present if involve spinothalamicSyringomyelia stroke tract, posterior column Example myelitis,UMN: upper motorsyringomyelia neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Neurologic Evaluation Spinal Cord Syndromes  Localization  examination  interpretation

Complete transection Brown Sequard (hemicord)

2001 2001 Brazis d NP Central cord Anterior spinal artery Neurologic Evaluation Spinal Cord Syndromes  Localization  examination  interpretation

Postero-lateral column Posterior column

2001 2001 Brazis d NP Anterior horn Anterior horn-pyramidal tract Neurologic Evaluation Spinal Cord Syndromes  Localization Complete  examination transection  interpretation

Motor: para-, tetraplegia (*spinal shock); LMN at the level Sensory: all modalities below the level 2001

ANS: urgency, retention, incontinence Brazis d NP Neurologic Evaluation Spinal Cord Syndromes  Localization Brown Sequard  examination (hemicord)  interpretation

Motor: ipsilateral hemiplegia Sensory: contralateral pain,

temperature; ipsilateral jps, 2001

vibratory (2 segments below) Brazis d NP Neurologic Evaluation Weakness Localization Spinal nerve Nerve plexus Peripheral nerve Parameter Muscle power Distribution Arms or legs Segmental of muscles examination (brachial or lumbo Specific groups muscle group involved grading systemsacral plexus) Type LMN LMN LMN

Atrophy interpretation: Prominent localizeProminent the lesionProminent TendonUMN reflexversus LMN versus non neurogenic Plantar reflex Flexor Flexor Flexor Sensory Absent in pure Present Present symptoms motor nerve Cervical Brachial plexus Carpal tunnel Example spondylosis injury syndrome

UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Cervical C1Neurologic-8 Evaluation Thoracic T1-12 Weakness Lumbar L1-5 Localization Spinal nerve Nerve plexus Peripheral nerve SacralParameterParameter MuscleS1- 5power Spinal nerve Distribution Arms or legs Segmental ofDistribution muscles examination of Segmental(brachial muscle or lumbo groupSpecific groups muscle group involvedmuscles grading systemsacral plexus) TypeType LMN LMN LMN LMN AtrophyAtrophy interpretation: ProminentProminent localizeProminent the lesionProminent TendonUMNTendon reflexversus reflex LMN Decreased versus non neurogenic Plantar reflex Flexor Flexor Flexor Plantar reflex Flexor Sensory Absent in pure Present Present symptomsSensory symptoms Present (segmental) motor nerve Cervical Brachial plexus Carpal tunnel ExampleAdditional deficits spondylosis injury syndrome Example Cervical spondylosis

UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Brachial plexusNeurologic C5-T1 Evaluation Trunk: upper/middle/lowerWeakness Cord: lateral/medial/posterior Localization Spinal nerve Nerve plexus Peripheral nerve LumbosacralParameterParameter Muscle plexus power L1-S2 Nerve plexus Distribution Arms or legs Segmental ofDistribution muscles examination of Arms or(brachial legs or(brachial lumbo Specificor lumbo groups- muscle group involvedmuscles grading systemsacralsacral plexus) plexus) TypeType LMN LMN LMN LMN AtrophyAtrophy interpretation: ProminentProminent localizeProminent the lesionProminent TendonUMNTendon reflexversus reflex LMN Decreased versus (involvednon neurogenic level)  Plantar reflex Flexor Flexor Flexor Plantar reflex Flexor Sensory Absent in pure Present Present symptomsSensory symptoms Present to nerve sistributionmotor nerve Cervical Brachial plexus Carpal tunnel ExampleAdditional deficits spondylosis injury syndrome Example Brachial plexus injury

UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Neurologic Evaluation Weakness Localization Spinal nerve Nerve plexus Peripheral nerve ParameterParameter Muscle power Peripheral nerve Distribution Arms or legs Segmental ofDistribution muscles examination of Specific(brachial group or lumbo Specific groups muscle group involvedmuscles grading system(mononeuropathysacral plexus) ) TypeType LMN LMN LMN LMN AtrophyAtrophy interpretation: ProminentProminent localizeProminent the lesionProminent TendonUMNTendon reflexversus reflex LMN Decreased versus ornon normal neurogenic Plantar reflex Flexor Flexor Flexor Plantar reflex Flexor Sensory Absent in pure Present Present symptomsSensory symptoms Specific to nerve distributionmotor nerve Cervical AbsentBrachial in pure plexus motor Carpal nerve tunnel Example Additional deficitsspondylosis injury syndrome Example Carpal tunnel syndrome, diabetic UMN:mononeuropathy upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Neurologic Evaluation Weakness Localization Spinal nerve Nerve plexus Peripheral nerve ParameterParameter Muscle power Peripheral nerve Distribution Arms or legs Segmental ofDistribution muscles examination of Distal (brachiallimb or lumbo Specific groups muscle group involvedmuscles grading system(polyneuropathysacral plexus) ) TypeType LMN LMN LMN LMN AtrophyAtrophy interpretation: ProminentProminent localizeProminent the lesionProminent TendonUMNTendon reflexversus reflex LMN Decreased versus non neurogenic Plantar reflex Flexor Flexor Flexor Plantar reflex Flexor Sensory Absent in pure Present Present symptomsSensory symptoms Present (distal limb) motor nerve Cervical Brachial plexus Carpal tunnel ExampleAdditional deficits spondylosis injury syndrome Example Guillain Barré syndrome, diabetic polyneuropathy UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Neurologic Evaluation Weakness Localization Neuromuscular junction Muscle Parameter Muscle power Distribution Symmetrical, proximal limb, of muscles examination Symmetrical, proximal limb ocular, bulbar muscle involved grading system Type Non neurogenic Non neurogenic

Atrophy interpretation: Absent localizeIn muscular the lesion dystrophies TendonUMN reflexversus LMNNormal versusor  nonNormal neurogenic or  Plantar reflex Flexor Flexor Sensory Absent Absent symptoms Myasthenia gravis Myositis, hypokalemia, Example Lambert Eaton syndrome thyrotoxic

UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Neurologic Evaluation Weakness Localization Neuromuscular junction Muscle ParameterParameter Muscle power Neuromuscular junction Distribution Symmetrical, proximal limb, ofDistribution muscles examination of Symmetric, usuallySymmetrical, proximal proximal limbs limb ocular, bulbar muscle involvedmuscles grading system TypeType Non neurogenicNon neurogenic Non neurogenic AtrophyAtrophy interpretation: AbsentAbsent localizeIn muscular the lesion dystrophies TendonUMNTendon reflexversus reflex LMNNormalNormal versusor  nonNormal neurogenic or  Plantar reflex Flexor Flexor Plantar reflex Flexor Sensory Absent Absent symptomsSensory symptoms Absent Myasthenia gravis Myositis, hypokalemia, ExampleAdditional deficits Ocular, facial, bulbar muscles Lambert Eaton syndrome thyrotoxic Example Myasthenia gravis, Lambert Eaton syndrome UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Neurologic Evaluation Weakness Localization Neuromuscular junction Muscle ParameterParameter Muscle power Muscle Distribution Symmetrical, proximal limb, ofDistribution muscles examination of Symmetric, usuallySymmetrical, proximal proximal limbs limb ocular, bulbar muscle involvedmuscles grading system TypeType Non neurogenicNon neurogenic Non neurogenic AtrophyAtrophy interpretation: AbsentPresent localize in muscularIn muscular the dystrophies lesion dystrophies TendonUMNTendon reflexversus reflex LMNNormalNormal versusor  or decreasednonNormal neurogenic or  Plantar reflex Flexor Flexor Plantar reflex Flexor Sensory Absent Absent symptomsSensory symptoms Absent Myasthenia gravis Myositis, hypokalemia, ExampleAdditional deficits Muscle pain/tenderness Lambert Eatonin inflammatorysyndrome thyrotoxic disease Example Myositis, hypok+, thyrotoxic UMN: upper motor neuron; LMN: lower motor neuron d NP STT: spinothalamic tract; MND: motor neuron disease Neurologic Evaluation Weakness PatternLocalization of Weakness Localization Upper examination limb: extensor muscles Upper motor neuron Lower limb: flexors muscles (corticospinal tract: CS) Hemiparesis grading system Upper motor neuron CS Multifocal, interpretation asymmetric Motor neuron disease weakness without Multifocal motor sensory involvement neuropathy Myasthenia gravis (uncommon) Multifocal, asymmetric Polyradiculopathy weakness with Multifocal neuropathy sensory involvement

d NP Amato AA, Russell JA. Neuromuscular disorders. New York, Mc Graw Hill Medical; 2008 Neurologic Evaluation Weakness PatternLocalization of Weakness Localization Symmetric examination weakness, Myopathy proximal or generalized Motor neuron disease without gradingsensory systeminvolvement NMJ disorder Generalized interpretation motor > sensory Polyradiculoneuropathy Asymmetric cranial muscles Myasthenia gravis with or without limbs Distal symmetric Distal myopathies motor only Distal spinal muscular atrophy Distal symmetric Length-dependent sensory > motor polyneuropathy

d NP Amato AA, Russell JA. Neuromuscular disorders. New York, Mc Graw Hill Medical; 2008 Neurologic Evaluation Weakness PatternLocalization of Weakness Localization Multiple examination nerves, asymmetric Multifocal polyneuropathy Multiple grading roots, systemasymmetric Polyradiculopathy Multiple interpretation nerves and roots Plexopathy single extremity Single root Monoradiculopathy Single nerve Mononeuropathy

d NP Amato AA, Russell JA. Neuromuscular disorders. New York, Mc Graw Hill Medical; 2008 Neurologic Evaluation Weakness  Clinical data gathering History Physical examination: motor system: tone/power; reflex cranial nerves sensory system  Interpretation, localization UMN versus LMN versus non neurogenic Motor pathway: cortex to muscle d NP