Hi, my name is Daniel Moon. I'm an attending physician at Moss Rehab at Albert Einstein Medical Center, and today we'll be talking about the physical examination of a patient with upper motor neuron syndrome. I do not have relevant financial relationships to disclose. The objectives of this talk will be to review the clinical assessment of patients with upper motor neuron syndrome, including the physical examination, functional assessment, and laboratory assessment. Patients with upper motor neuron syndrome can have dysfunction due to hyperreflexia, muscle overactivity, weakness, and impaired motor control, including feedback mechanisms such as sensation and proprioception, as well as developing joint contractures and deformity. This will lead to abnormal movements or postures, which can cause involuntary interference with function, as well as compensatory behaviors affecting their goals, including posture, mobility, and activities of daily living. When evaluating a patient, the following clinical questions should be answered. One, does the joint have limitations due to fixed shortening or contracture of the muscles and other connective tissues, such as the ligaments, the joint capsule, or even a joint fusion? Two, which muscle groups can the patient voluntarily activate and to what degree? Three, is the muscle spastic, in other words, activated in response to stretch? Four, is the muscle activated as an antagonist during active movement generated by an agonist? This is also known as dyssynergy or co-contraction activity. And five, how does the muscle hypertonia assist with or impair function? Physical examination begins with a visual inspection, oftentimes as a patient is seen in the waiting area or as they come into the room. Take note of the sitting posture, especially if they are in a wheelchair, the resting posture of the joints, as well as any associated reactions as they walk or during a sit-to-stand transfer, and if they yawn or cough during the appointment. The skin assessment is a special appointment as these patients are prone to develop redness and maceration in the folds of the skin due to moisture buildup. But they can also develop redness and skin breakdown from stretching of the skin over bony prominences due to joint deformities. When assessing passive range of motion, be aware of the proximal and distal joint position when testing joints to account for muscles that cross more than one joint. For example, at the shoulder and elbow, the triceps longhead acts not only as a elbow extensor, but also a shoulder extensor. And at weak adductor, the biceps can be both a shoulder and elbow flexor. For the wrist and hand, this is especially important as the flexor digitorum profundus, flexor digitorum superficialis, and flexor pollicis longus act as both wrist and finger or thumb flexors. Therefore, composite wrist-hand extension versus wrist extension alone is important to elucidate the role of the finger flexors in the wrist flexion deformity. The intrinsic hand muscle assessment is also complicated as these muscles can act as metacarpophalangeal joint flexors, proximal interphalangeal joint, and distal interphalangeal joint extensors. When assessing the intrinsic hand muscles, flex the wrist fully to reduce the effect of the extrinsic finger flexors on the metacarpophalangeal and interphalangeal joints of the hand. When assessing passing range of motion in the lower limbs, be aware that the flexor digitorum longus, flexor pollicis longus, extensor digitorum longus, and extensor pollicis longus have an effect on not only the interphalangeal joints of the toe, but also the metatarsophalangeal joints of the foot, the subtalar joint, and the tibiotalar joint. The peroneal muscles, tibialis anterior and posterior, as well as the extrinsic toe flexors and extensors all exert an effect on the ankle and the subtalar joint. The knee and ankle are also connected via the gastrocnemius, which acts as a weak knee flexor in addition to plantar flexing the ankle. Oftentimes, a patient may flex their knee in order to help gain more dorsiflexion at the ankle. Therefore, it's important to compare ankle dorsiflexion with the knee flexion extended to assess the contribution of the gastrocnemius versus the soleus to a equinus deflection. At the hip and knee, be aware that the hamstrings are knee flexors and hip extensors. Therefore, knee range of motion can change from the supine to seated position. The popliteal angle test is a good way to elucidate this relationship. The rectus femoris is a knee extensor and hip flexor. Therefore, Eli's test in the sideline or prone position can be done to elucidate this relationship. And finally, the sartorius is a hip flexor and external rotator in addition to being a knee flexor. The hip is also connected to the trunk pelvis via the psoas and iliacus, which can have effects on the trunk and pelvis in addition to being hip flexors. Other muscles at the hip can have multiple effects due to the fact that the hip is a ball and socket joint. The gluteal muscles are hip flexors and the gluteus muscles are hip flexors. The hip adductors, extensors, and rotators, the pectineus and adductor brevis longus are hip adductors and weak hip flexors, whereas the gracilis and adductor magnus are hip adductors and hip extensors. Therefore, it's important to check the hip internal external rotation, adduction, adduction, and flexion extension to elucidate which muscles are responsible for the hip deformity and knee deformity. This brings us to question one. Passive extension of the knee would likely increase as the patient goes from the seated to supine position due to shortening of which muscle? A, rectus femoris. B, semitendinosus. C, biceps femoris short head. D, gastrocnemius. The correct answer is B, semitendinosus. The semitendinosus originates at the ischial torosity and inserts onto the pes anserinus on the tibia. Thus, this muscle along with the semitendinosus and along the biceps crosses both the hip and knee joint. And as a result, flexion of the hip in the seated position would increase tension on this muscle and place further restriction on passive extension of the knee. This would result in less passive range with knee extension in the seated than the supine position if this muscle is spastic or contracted. When assessing strength of the affected limbs, perform isometric strength testing with caution as this can be misleading, especially at the elbow and finger flexors, knee extensors and ankle plantar flexors as the patient can utilize muscle overactivity to their advantage making the strength grade inaccurate. Sometimes it's better assess active range of motion and alternating movements at select joints. First assess active range of motion against gravity. If they're unable to perform this, then eliminate the effects of gravity and reassess. Alternating movements are also helpful. When doing this, assess the quality of movements and temporal spatial asymmetry between flexion extension phases. For example, the speed and amplitude of the movements. This can also help elucidate the presence of spastic co-contraction activity. Along a similar line, Colin and Wade in 1990 developed the motricity index for motor impairment after stroke. This grades strength using a point system, normal strength being 33 points, ability to move the limb against gravity, 25 points, less than anti-gravity strength, 14 points and a palpable flicker, nine points. The exception being pinch grip, which uses a 2.5 centimeter cube to assess strength in the finger flexors. The sum of three points plus one equals 100 points for each limb for a total of 400 points. For the upper limb, the shoulder, elbow and hand are assessed and for the lower limb, the hip, knee and ankle are assessed for this point system. Question two, the results of standard isometric strength testing of a spastic paretic limb during physical examination may result in falsely increased strength grade for which of the following reasons? A, patient utilizes tone to resist examiner. B, examiner may not differentiate slight differences in strength because lower limbs are stronger than examiner's upper limbs. C, patient is unable to follow commands. D, presence of soft tissue contracture. The correct answer is A, patient utilizes tone to resist examiner. Patients with spastic paresis can elucidate hypertonia during isometric muscle strength testing, especially in the flexors of the upper limbs and extensors of the lower limbs, resulting in skewed muscle strength grades. Range of motion limitation should always be considered with strength testing in all patients and strength testing of the lower limbs can be less sensitive in detecting focal weakness in any patient, especially when they are much stronger than examiner's upper limbs. Impaired command following would likely result in falsely reduced muscle strength grades. It's also a good idea to assess the patient's reflexes in the affected limbs to not only establish the presence of upper motor neuron pathology, but can also detect coexisting lower motor neuron pathology. Oftentimes a patient may have critical illness polyneuropathy or associated compression neuropathies due to their deformities. In addition to detecting muscle stretch reflexes, pathologic reflexes are also helpful, such as Hoffman's reflex, Babinski reflex, as well as the presence or absence of clonus. Clonus can occur in any muscle group as shown in the video to your right, where a patient's intrinsic hand muscles are being stretched, eliciting clonus. Okay. To complete the neurological exam, it's also important to assess sensory, such as light touch, pain, and joint proprioception, as well as the presence of hemi-neglect, as this can affect compliance and offers an opportunity to educate the patient and caregiver. All of you should be familiar with the modified ASHRAW scale from Residence. Modified ASHRAW scale from Residency, but it's important to note that range of motion should be completed in one second to ensure repeatability from visit to visit. Zero indicates no increase in muscle tone, whereas one indicates a slight increase in muscle tone manifested by catch and release or minimal resistance at the end of range of motion. One plus indicates a slight increase in muscle tone manifested as a catch followed by minimal resistance throughout less than half of range of motion, and two indicates more marked increase in muscle tone throughout most of range of motion. With a modified ASHRAW scale of three, there is considerable increase in muscle tone. Passive movement is difficult. And with a modified ASHRAW scale grade of four, the affected part is rigid inflection or extension. The TARDU scale, although it's less commonly used, does take into account the presence of velocity-dependent stretch resistance, as well as clonus. It consists of two parts. Part one, quality of muscle reaction or Y. Zero indicates no resistance throughout course of passive movement, whereas one indicates slight resistance throughout course with no clear catch. Two indicates a clear catch at a precise angle followed by release. It takes into account the presence of clonus with grade three, which indicates fatigable clonus less than 10 seconds. In grade four, non-fatigable clonus more than 10 seconds. Grade five is similar to grade four on the modified ASHRAW scale, whereas the joint is immobile, likely due to contracture. The second part of the TARDU scale is the spasticity angle. This takes velocity dependence into account. You range the joint at three different speeds while recording the range of motion or angle of catch. The first velocity is as slow as possible or V1. Second, you range the joint at the speed of a limb segment falling or within one second. And third, you range it as fast as possible. XV1 is a full range of motion achieved when ranging the joint as slow as possible. XV3 is the angle of catch seen at V2 or V3. The spasticity angle is equal to the full range of motion minus the angle of catch seen at V2 or V3. Shown here is a worksheet from Grasius et al. 2010. I highly recommend you read the original article and fill out one of these worksheets while examining a patient. Question three, when examining a patient with spastic hemiparesis, you find that their elbow has full range of motion when ranged slowly, but there is a catch followed by resistance at 100 degrees when passively extending the elbow faster. There is no clonus elicited in the elbow flexors. What is the modified Ashworth scale grade and what is the modified Tardieu scale grade in spasticity angle? A, MAS1+, MTS3, 100 degrees. B, MAS2, MTS2, 80 degrees. C, MAS2, MTS1, 80 degrees. Or D, MAS2, MTS2, 100 degrees. The correct answer is D, modified Ashworth scale 2, modified Tardieu scale 2, and spasticity angle of 100 degrees. The patient's elbow flexors demonstrate resistance to stretch during greater than half a range of motion and therefore is considered modified Ashworth scale grade 2. There is a clear catch at 100 degrees followed by release. Thus, modified Tardieu scale grade is also 2. Recall that the spasticity angle is equal to the range of motion minus the angle of catch. Since range of motion is full, it is zero degrees and the angle of catch is at 100 degrees. Therefore, the spasticity angle is at 100 degrees. When assessing function, we're often known with the functional independence measures or FIM scores. We observe patients performing specific tasks and assign a score depending on how much assistance they may require. However, this is not sensitive at higher functional levels. For example, ambulation with a rolling walker and cane are both considered modified independent. For the upper limb, there are several measures including the modified Frenchie scale and Barthol index, which assess ADLs. Fugal myoparts C and D assesses grasp as well as coordination and speed. The 9-0 PEG test will also assess grasp and coordination and speed. In addition, we can perform clinical observation of a patient performing specific tasks such as reaching into space and grasp and release of objects. Functional assessment of the lower limb is primarily centered around gain and mobility. We can assess this in our clinic by measuring walking velocity either via the 10-meter walk test or six-minute walk test. The timed up and go test or TUG measures not only walking, but also transfers and turns as a patient is timed while they rise from the chair, walk three meters, turn 180 degrees, walk back to the chair, turn another 180 degrees and sit back down. In addition, many times we perform clinical observation of their gait where we assess for asymmetry and abnormal joint postures while they're walking. And functionally, we can assess their swing phase clearance and limb advancement as well as their stance phase stability and center of mass advancement. Laboratory motion analysis, when available, can be utilized to more objectively assess a patient's movement and function. This includes temporal-spatial parameters, kinematics, specifically joint angles, kinetics, which are joint moments and powers, as well as dynamic polyelectromyography, recordings of muscles while they are performing certain movements. This should be viewed as extension of a physical examination, not a replacement. At the bottom is an example of temporal-spatial parameter analysis. Shown is gait mat data for a patient with right spastic hemiparesis. The measurements include velocity for this patient, which is 0.19 meters per second. And you can see in red are the left steps, which are 0.09 meters long and in green are the right steps, which are 0.44 meters. Shown here is an example of kinematic data on a patient with right spastic hemiparesis. The blue lines indicate left lower limb data, the red lines indicate right lower limb data, and the gray lines indicate the upper and lower limits of normal age and velocity matched data. The vertical lines are the transition between stance and swing phase. The arrow highlights the knee kinematic data, which shows that the right knee does not flex during swing phase in comparison to the left, as shown by the lack of a hump between 60 and 100%. Shown here is an example of dynamic polyelectromyography recordings on a patient with right spastic equinus deformity. The solid bar indicates when the muscle should be active. The vertical line shows when stance phase ends and swing phase begins. You can see the right tibialis anterior fires following initial contact and during swing phase, the recruitment might be decreased. But you can also see the gastrocnemius and soleus are active following initial contact as well, as well as during swing phase. Repetitive bursts of activity are also seen, which indicate the presence of clonus. In summary, patients with upper motor neuron syndrome can have underlying contractures and coexisting lower motor pathology contributing to their dysfunction. Physical examination of an individual with upper motor neuron syndrome should include neurological examination, as well as assessment of range of motion, tone, movement, and function. Be aware of proximal and distal joint orientation when measuring range of motion to account for muscles that cross more than one joint. The modified Ashford scale and modified Tardieu scale are repeatable measures of tone when appropriately utilized. And one should exercise caution with isometric strength testing as a patient can utilize tone to resist examiner. Thank you very much for your attention. Please do not hesitate to email me if you have any questions.

upper motor neuron syndrome

muscle overactivity

clinical evaluation

range of motion

reflex assessment

physical examination