Upper vs Lower Motor Neuron Lesion

Inspection

Muscle Bulk

 Loss of muscle bulk in LMN and late in UMN

 Symmetry

Muscle Girth

Fasciculations

 present in LMN, none in UMN

Muscle Tone

 flexion/extension, pronation/supination of joint through its ROM

Hypotonia

o flaccidity

o LMN lesions, spinal shock, cerebellar lesions

Hypertonia

 Spasticity - UMN lesion. Pyramidal tract involved

 limb moves, then catches, and then goes past catch (clasp-knife)

o test by rapidly supinating forearm

 Rigidity

o UMN lesions, extrapyrimidal tract lesion

o increased tone throughout ROM (cog-wheeling, lead-pipe)

o circumducting the wrist

Power

 UMN
 o flexors > extensors in upper limbs

o extensors > flexors in lower limbs

 LMN

o reduced power in specific motor neuron distribution

 deltoids - arm abduction - C5 C6 (axillary)

 biceps - elbow flexion - C5 C6 (musculocutaneous)

 triceps - elbow extension - C6 C7 C8 (radial)

 thumb flexion - C6 C7 (median)

 wrist extensors - C7 C8 (radial)

 interossei of hand - finger abduction/adduction - C8 T1 (ulnar)

 hip flexion - L1 L2 L3 (femoral)

 hip adduction - L2 L3 L4 (obturator)

 hip abduction - L4 L5 S1 (superior gluteal)

 knee extension - L2 L3 L4 (femoral)

 knee flexion - L5 S1 S2 (sciatic)

 ankle dorsiflexion - L4 L5 (deep peroneal)

 ankle plantar flexion - S1 S2 (tibial)

 foot inversion - L4 L5 (posterior tibial)

 foot eversion - L5 S1 (superficial peroneal)

 compare between L and R

 GRADE

o 0 nil

o 1 flicker of movement

o 2 movement cannot overcome gravity

o 3 movement cannot overcome any resistance

o 4 movement is weaker than normal

o 5 normal
Pronator Drift

 have the patient stand with eyes closed and arms held straight out and hands supinated

 + → patient cannot maintain this position

o muscle weakness (pronation and outward drift)

o UMN lesion (pronation and downward drift)

 standing problemes

Fine Finger Movements

 ask patient to touch each finger to crease of thumb (show patient how) and speed it up

 look for right and left differences, slow if UMN lesion

Clonus

 Ankle or Patellaer clonus in UMN Lesion

Reflexes

Deep Tendon Reflexes

 biceps tendon (C5-6)

 brachioradialis tendon (C5-6)

 triceps tendon (C6-8)

 knee jerk (L2-4)

 Achilles tendon (S1-2)

 hyperactive ankle jerk → examine for clonus at knee and ankle

 absent → use reinforcements (teeth clenching)

 UMN → hyperreflexia, but may be flaccid

 LMN → diminished reflexes

Grading

 0 nil

 1 low normal
  2 normal

 3 high normal

 4 clonus (sustained > 3 beats)

 note if reinforcements used (teeth clenching, hand grips)

Babinski’s reflex (L5-S1)

 + → dorsiflexion of the big toe with/without fanning of the other toes (UMN lesion)