1. Muscle Tone

• Definition: The resistance of muscle to passive stretch during resting state.

• Types:

  • Normal tone: Slight resistance felt when passively moving the limb.

  • Hypertonia: Increased tone, seen in upper motor neuron lesions. Subtypes:

    • Spasticity: Velocity-dependent increase in tone (e.g., stroke, MS).

    • Rigidity: Uniform resistance (e.g., Parkinson’s disease).

  • Hypotonia: Decreased tone, common in lower motor neuron lesions or acute UMN lesions.

• Assessment: Passively move shoulder, elbow, wrist, and fingers; note resistance.

2. Muscle Strength

• Definition: The force a muscle can exert voluntarily.

• Grading (Medical Research Council scale):

  • 0: No contraction

  • 1: Flicker or trace of contraction

  • 2: Movement with gravity eliminated

  • 3: Movement against gravity

  • 4: Movement against some resistance

  • 5: Normal power

• Testing:

  • Shoulder abduction/adduction (C5-C6)

  • Elbow flexion/extension (C5-C7)

  • Wrist extension/flexion (C6-C8)

  • Finger grip (C8-T1)

  • Finger abduction (ulnar nerve, T1)

3. Reflexes

• Definition: Automatic muscle responses to specific stimuli, assessing integrity of reflex arcs and CNS pathways.

• Upper Limb Reflexes:

  • Biceps reflex (C5-C6): Strike biceps tendon; forearm flexion indicates intact reflex.

  • Brachioradialis reflex (C6): Strike radius near wrist; forearm flexion and supination.

  • Triceps reflex (C7-C8): Strike triceps tendon; elbow extension.

• Abnormal findings:

  • Hyperreflexia: Indicates UMN lesion.

  • Hyporeflexia/absent reflex: Suggests LMN lesion or peripheral neuropathy.

  • Clonus: Repetitive reflex beats, suggests UMN lesion.

4. Sensory Examination

• Modalities to test:

  • Light touch (via cotton wool or brush)

  • Pain (pinprick)

  • Temperature (cold tuning fork or test tubes)

  • Proprioception (position sense of fingers)

  • Vibration (128 Hz tuning fork on bony prominences)

  • Discriminative sensation:

    • Stereognosis: Identifying objects by touch

    • Graphesthesia: Recognizing numbers drawn on skin

    • Two-point discrimination

• Nerve distributions: Assess median, ulnar, radial nerves and dermatomes C5-T1.

5. Coordination Tests

• Purpose: Assess cerebellar function and proprioception.

• Tests:

  • Finger-to-nose test: Patient touches your finger then their own nose repeatedly.

  • Rapid alternating movements (pronation/supination of hands): Look for dysdiadochokinesia.

  • Finger tapping: Speed and rhythm assessment.

• Abnormalities: Dysmetria (overshoot or undershoot), intention tremor, irregular movements.

6. Special Signs

• Pronator Drift:

  • Test: Patient holds arms outstretched, palms up, eyes closed.

  • Positive: One arm pronates and drifts downward, indicating contralateral corticospinal tract lesion.

• Tinel’s Sign (at wrist):

  • Test: Tap over median nerve at the wrist.

  • Positive: Tingling sensation in median nerve distribution, suggesting carpal tunnel syndrome.

• Phalen’s Test:

  • Test: Patient flexes wrists fully, pressing backs of hands together for 60 seconds.

  • Positive: Tingling in median nerve distribution, indicating median nerve compression.

7. Nerve Stretch Tests

• Purpose: Detect nerve root irritation or radiculopathy.

• Examples:

  • Spurling’s test: Extension and rotation of neck to the affected side to elicit radicular arm pain.

  • Upper limb tension tests: Various maneuvers to stretch brachial plexus or cervical nerve roots.

8. Peripheral Nerve Examination

• Median nerve:

  • Motor: Thumb opposition and abduction

  • Sensory: Palmar aspect of lateral 3.5 fingers

• Ulnar nerve:

  • Motor: Finger abduction/adduction, flexion of 4th and 5th digits

  • Sensory: Medial 1.5 fingers

• Radial nerve:

  • Motor: Wrist and finger extension

  • Sensory: Posterior arm and dorsum of hand (lateral 3 fingers except fingertips)

9. Clinical Correlation

• Upper Motor Neuron Lesion (UMN):

  • Weakness with increased tone and hyperreflexia, positive Babinski, no muscle atrophy initially.

• Lower Motor Neuron Lesion (LMN):

  • Weakness with hypotonia, hyporeflexia, muscle wasting, fasciculations.

• Peripheral neuropathy:

  • Symmetrical distal sensory loss, decreased reflexes.

• Radiculopathy:

  • Dermatomal sensory loss, motor weakness in nerve root distribution, positive nerve stretch tests.

• Plexopathy or Mononeuropathy:

  • Mixed motor and sensory deficits following peripheral nerve distribution.

10. Practical Examination Tips

• Ensure patient comfort and privacy.

• Use systematic side-to-side comparison.

• Start with observation for atrophy, fasciculations, tremors.

• Always correlate findings with patient history.

• Document muscle strength and tone carefully.

• Note asymmetry and focal deficits.

• Repeat reflex tests if uncertain; confirm with reinforcement techniques.