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   THE LIMITED CLINICAL NERVE EXAM

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Liberty You will find in this section hot NEW articles which we feel are of national importance to all folks.  These in-depth scientific forensic works are brought to you as a free service from AAJTS.  If you wish to become a member of the Academy and receive weekly Articles, join now!

THE LIMITED CLINICAL NEUROLOGICAL EXAMINATION

      The Neurological portion of your examination would include testing the musculature associated with the nerve level in question.  Further, the tests your reviewed in Orthopedics would be coordinated to determine nerve level integrity.  Thus whenever you examine the spine or extremities you coordinate your Orthopedic examination with your neurological examination including the deep tendon reflexes, sensation testing when appropriate for the nerve level relative to your specific Kinesiological weakness testing for specific nerve levels.   

 

DIFFERENTIAL DIAGNOSIS BEFORE THE EXAM BEGINS THROUGH ATYPICAL GAITS

      When the patient first enters your office, observe for atypical gaits.  Of course, you can add your gait analysis any time the patient ambulates. 

1.     When an inverted foot is noted upon walking, examine the lateral leg compartment.

2.     When the patient is noted as walking on their heels, examine their posterior leg compartment.

3.     When the patient is noted as dragging their toes, examine the anterior leg compartments.

4.     Look for the Waddling gait of Pagets or Duchennes Muscular Dystrophy.

5.     Toe Walking Gait of Muscular Dystrophy.

 

DEEP TENDON REFLEXES: 

     In your review of the orthopedic section, we detailed deep tendon reflex testing.  Here we will delve deeper into the exact mechanism for such tests. 

  

CERVICAL SPINE AND UPPER EXTREMITIES: 

    Of course, there are three basic deep tendon reflexes, which evaluate the integrity of the C5, C6 and C7 nerve supply.  These are known as the biceps reflex, the Brachioradialis reflex, and the triceps reflex.  Deep tendon reflexes are of course considered a lower motor reflex.  Here the signal translates to the posterior horn of the spinal cord, thought internuncial neurons into the anterior horn cells and returning through the peripheral nerves to the musculature.

 

BICEPS REFLEX Ė C5 

     Although there are multiple innervations to the biceps via C5 and C6, primary innervation is associated with C5. 

     Ask the patient to place their arm over you contralateral forearm.  With his arm relaxed, tap your thumbnail with the arrow end of the reflex hammer.  The biceps will jerk slightly for a normal response.  If you attempt the test a few times and no response is elicited perhaps there is a lower motor neuron lesion somewhere between the C5 nerve level and the innervation of the biceps muscles.  However if the elicited response is excessive it may be associated with an upper motor neuron lesion.  An example of an upper motor neuron lesion would be cervico-basilar infarction or stoke.  An example of a lower motor neuron lesion may be disc herniation with subsequent peripheral nerve irritation.  Record reflexes as 2 plus for normal, 3 plus or 4 plus for increased or 0 to 1 plus for decreased reflexes.  The opposite extremity reflex and coordinate date.

 

BRACHIORADIALIS REFLEX Ė C6 

    Although there are multiple innervations to the Brachioradialis via C5 and C6, primary innervation is associated with C6. 

     Your doctor patient position is the same as with the C5 test.  With the flat edge of the reflex hammer, tap the brachio-radialis tendon at the distal end of the radius to elicit a radial response.  Test the opposite arm ad compare and record the date.

 

TRICEPS REFLEX Ė C7 

     The triceps muscle is innervated by the radial nerve primarily C7.   

     The doctor patient position is similar to the previous test save the fact that you elevate your stabilizing arm slightly.  When the patient is relaxed, tap the triceps tendon where it crosses the olecranon fossa with the arrow end of the reflex hammer.  Compare bilaterally and record data. 

 

LUMBOSACRAL SPINE AND LOWER EXTREMITIES: 

PATELLAR REFLEX Ė L2, 3, AND 4 

     Although the patella reflex, or knee jerk, is a deep tendon reflex, innervated by L2, L4 and L4 primary innervation comes from L4. 

     Ask the patient to sit on the edge of the examining table with their legs dangling free.  Palpate the soft tissue depression on either side of the infrapatelar tendon.  Tap the tendon with the arrow end of the reflex hammer, with a short, wrist action.  If the test is difficult to elicit, ask the patient to grasp his their hands together and attempt to pull them apart as you attempt the test.  Compare bilaterally and records the date. 

 

ACHILLES TENDON REFLEX Ė S1 

     The S1 nerve level innervates the Achilles tendon deep reflex. 

     Ask the patient to sit on the edge of the examining table with their legs dangling.  Gently dorsiflex the foot.  Tap the tendon with the flat end of the reflex hammer.  If the test is difficult to elicit, as the patient to grasp their hands together and attempt to pull them apart as you attempt the test.  Compare bilaterally and record the data for later synthesis. 

 

COMPLETE LIST OF THE DEEP TENDON REFLEXES 

1.     Maxillary reflex aka Jaw Jerk innervation Cranial Nerve V3.  When there is a sudden closure of the jaw when you strike the middle of the chin, as the mouth was initially open.

2.     Bicep reflex C5 primarily (C6)

3.     Triceps reflex C6 primarily (C7)

4.     Periosteoradial C7 primarily (C6, C8)

5.     Periosteo-Ulnar reflex C8, T1.  There is extension and ulnar abduction of the wrist when the styloid process of the ulna is struck.

6.     Wrist Reflexes C7, C8.  There is flexion or extension motion when the corresponding tendons are struck.

7.     Patellar reflex L4, (L2, L3).  There is extension at the knee when the patellar tendon is struck. Absence of the reflex is known as WESTPHALíS SIGN.  When the reflex cannot be obtained and you have the patient clasp their hands together, clench, and the reflex is obtained you have utilized the JENDRASSIK method of reinforcement.

8.     Achilles reflex S1, S2. 

 

NERVE LEVEL & PERIPHERAL NERVE SENSATION TESTING AND VERIFICATION 

     Sensory testing for the cervical spine is associated with the integrity of the dermatomes.  Dermatomes into the upper extremities include levels C5 to T1.  The following is an outline the brachial plexus distribution of the upper extremities.

C5 Ė Lateral arm Ė Axillary nerve

C6 Ė Lateral forearm, thumb, index, and half of middle finger Ė sensory

Branches of the Musculo-Cutaneous nerve.

C7 Ė Middle finger

C8 Ė Ring and little fingers, medial forearm Ė medial antebrachial-cutaneous nerve.

T1 Ė Medial arm Ė medial brachial cutaneous nerve.

While performing the tests, it is expedient to utilize the Waltenberg pinwheel.  If the patient states that they feel the wheel with no abnormal sensation write intact.  If there is numbness write not intact. 

The following is a chart of the root to be tested, muscles associated as well as area of sensation.

 

ROOT        DISC       REFLEX  MUSCLES  SENSE 

C5             C4-C5     Biceps      Deltoid    Lateral Arm                          Biceps                   Axillary nerve

 

C6              C5-C6    Brachio-   Biceps  Lateral Forearm

                            Radialis  Wrist Extensors Musculo                                                                   cutaneous

C7               C6-C7    Triceps     Triceps      Middle finger

                              Finger Extensors         Wrist Flexors

C8               C8-T1    Finger flexors   Medial Forearm                           Intrinsic muscles    Me. Ant. Brach.                              Of the hand  Cutaneous nerve.

T1               T1-T2           Intrinsic muscles    Medial Arm

                     Of the hand     Med. Brach. Cutaneous Nerve. 

Next, test the peripheral nerves.  Utilize the following chart for evaluation of the peripheral nerves.

 

NERVE        MOTOR TEST         SENSATION

 

Axillary           Deltoid             Lateral Arm Ė Deltoid patch on Upper arm

 

Musculo-Cutaneous  Biceps       Lateral Forearm

 

Radial            Wrist Extension     Dorsal web space between Thumb and index finger

 

Median          Thumb Pinch         Distal radial aspect Ė index Finger

 

Ulnar              Abduction Ė little     Distal ulnar aspect Ė little finger

  

SENSATION TESTING FOR THE LUMBAR SPINE 

   Testing of the dermatomes of the lower extremity serves to indicate nerve level of the lumbosacral spine.  The following chart will coordinate nerve level with reflex, musculature and area of sensation.

 

ROOT        DISC         REFLEX   MUSCLES         SENSATION

 

L4               L3-L4          Patellar        Anterior                 Medial leg and Tibialis Foot

 

L5               L4-L5          None           Extensor                Lateral leg &  Hallucis longus  dorsum of foot

 

S1               L5-S1          Achilles       Peroneus Longus   Lateral Foot and Brevis

 

THE SUPERFICIAL REFLEXES 

     The superficial reflexes (i.e. abdominal, cremasteric, and anal reflexes) or upper motor neuron reflex testing is mandatory when we suspect specific lesion associated with an upper motor neuron lesion.  The absence of the superficial reflex perhaps indicates an upper motor neuron lesion.  If the superficial reflex is absent and the deep tendon reflex is increased, this will add evidence to indicate an upper motor neuron lesion and reason for consultation for Neurodiagnostic testing. 

 

ABDOMINAL REFLEX    

     The patient is asked to lie in the supine position.  Place the arrow end of the reflex hammer upon the abdomen and stroke each section of the abdomen, noting whether the umbilicus moves toward the area being stroked.  The lack of an abdominal reflex may indicate an upper motor neuron lesion provided you perform the test correctly.  You may also detect a lower motor neuron lesion because the upper muscles of the abdomen are innervated form T7 through T10.  The lower muscles from T10 to L1.  Thus, lack of a reflex will indicate the approximate level of a lower motor neuron lesion.

 

CREMASTERIC REFLEX 

    The patient is asked to lie in the supine position.  Stroke the inner aspect of the upper thigh with the arrow end of the reflex hammer.  If the reflex is elicited the scrotum will be pulled upward as the cremasteric muscle contracts.  This is associated with a T12 level.  If the reflex is reduced or absent bilaterally this may indicate an upper motor neuro lesion, while a unilateral absence indicates a probable lower motor neuro lesion between L1 and L5. 

 

ANAL REFLEX 

     The patient is asked to lie in the prone position.  Gently touch the perianal skin.  The external and anal sphincter muscles (S2, S3, S4) would contract in response.

  

ANAL WINK REFLEX 

     If you are unable to elicit a response, take a finger cot, place your finger gently within the anus, and pull out.  The anus should contract as if to wink.

 

CLINICAL UNDERSTANDING OF UPPER AND LOWER MOTOR NEURON LESIONS

      Before a complete review of the pathological reflexes to determine upper and lower motor neuron lesions, a complete understanding of these signs and symptoms will make the diagnosis of the pathological reflex via common scientific sense. 

     The motor innervation of the striated musculature is innervated by the Pyramidal system.  The Pyramidal pathway conducts impulses to the spinal cord anterior horn cells associated with isolated movements of the hands ad fingers which form the basis for the development of manual skills.  In fact, it has been estimated that 55% of all pyramidal fibers end in the cervical cord, 20% in the thoracic and 25% in the lumbosacral segments.  Therefore, the muscles of the upper extremity are more affected than the muscles of the lower extremity and the distal muscles (hand) are most affected compared to the proximal because they have more motor units for complex actions. 

 

UPPER MOTOR NEURON LESION AKA SPASTIC PARALYSIS AKA SUPRANUCLEAR PARALYSIS

 1.     Initially there is loss of tone in the affected muscles (hypertonia)

2.     Soon after the muscles gradually become resistant to passive movement and yield SPASTIC PARALYSIS.

3.     The myotatic deep tendon reflexes, especially in the leg, are increased in force and amplitude known as HYPERREFLEXIA.

4.     The SUPERFICIAL REFLEXES are lost or diminished.

5.     Positive Babinskiís Sign is noted.

6.     If the suspected lesion is above the pyramidal decussation, the symptoms will be found on the contralateral side.

7.     If the suspected lesion is below the pyramidal decussation, the symptoms will be found on the ipsilateral side.

     With an upper motor neuron lesion the first manifestation will be a disturbance in muscular tonus, expressed as hypotonia.  However, within 2-3 weeks changes occur leading to hypertonia bringing about hyperreflexia.  Thus when hyperreflexia is noted the lesion must be considered at least 2-3 weeks old. 

     The reason that UMNLís lead to a loss of the superficial reflexes is due to the fact that there is retrograde degeneration.  This retrograde degeneration causes degeneration of the association neuron and the afferent sensory neuron in the reflex arc. 

     In the geriatric population, there is a tendency for the superficial abdominal reflexes to be absent.  Thus, this may not indicate an UMNL. 

     It must also be noted that absence of the superficial abdominal reflexes is not in itself indicated of a MNL.  Finally, in UMNLís flaccidity and atrophy will be greater in the upper extremities in the distal aspect because there are more motor units present.   

 

LOWER MOTOR NEURON LESION AKA FLACCID PARALYSIS LESION 

1.     Muscle fibers, which have been deprived of their afferent nerve innervation, become completely paralyzed.

2.     All reflexes, deep tendon and superficial are abolished and the musculature become flaccid.

3.     The muscle fibers begin to undergo progressive atrophy.

4.     There are marked fibrillary tremors and fasciculations noted in the affected musculature within three weeks of the initial injury.

5.     Lower motor neuron lesions produce ipsilateral symptoms except for the Ivth cranial nerve because the IV crosses. 

     It must be noted that when the lesion is found in the anterior r horn cells, it will take two weeks or more for paralysis and flaccidity to occur.  Generally, marked fasciculations and fibulation occurs while the LMN is degenerating then they disappear.  If the fasciculations occur months to years later, it indicates that there is some nerve regeneration.  When this is noted you will have excellent results 

 

PATHOLOGICAL REFLEXES COMPLETE BY BODY REGION 

     Pathological reflexes act reciprocally to the previous.  The presence of a pathological reflex may indicate an upper motor neuron lesion and its absence indicates the norm. 

HEAD 

1.     BABINSKIíS PLATYSMA SIGN  

If resistance to flexion of the chin against the chest is presented or opening the mouth, the platysma on the side will contract, whereas the affected side will not.

 

2.     HEAD RETRACTION REFLEX

Specific downward percussion upon the upper lip with the patientís head slightly in forward flexion produces head and neck bending followed by brisk head retraction.

 

3.     Mc MCCARTHYíS SIGN AKA The Glabella Reflex 

With the patient in the supine position gently percuss the Supraorbital ridge which results in the reflex contraction of the Obicularis Oculi muscle.

 

4.     SNOUT REFLEX 

Specific tapping of the middle of the upper lip induces an exaggerated reflex contraction of the lips.

  

UPPER EXTREMITIES 

1.     BABINSKIíS PRONATION SIGN 

The patient is in the sitting position.  Ask the patient to place their hands in approximation with the palms upward.  Place your fists below the patient hand.  Bring your fists upward jarring the patientís hands several times.  The affected hand will fall in PRONATION, and the sound hand will remain horizontal.

 

2.     BECTEREWíS SIGN 

The patient is in the sitting position.  Ask the patient to flex and relax the forearms several times.  The paralyzed forearm will fall back slowly and in a jerky manner, even when contractures are mild.

 

3.     CHADDOCKíS WRIST SIGN 

Gently stroke the ulnar side of the forearm near the wrist.  Flexion of the wrist, and extension and fanning of the fingers will indicate the affected hand. 

 

4.     TROMNERíS SIGNS AKA Finger Flexion Reflex 

A positive sign is elicited by specifically tapping the palmar surface or the tips of the middle three fingers produces prompt flexion of the fingers.

 

5.     GORDONíS FINGER SIGN 

Extension of the flexed fingers or the thumb and index finger when pressure is exerted over the Pisiform bone.

 

6.     HOFFMANíS SIGN 

This sign is demonstrated by a clawing movement of the fingers produced by the flicking of the distal phalanx of the index finger.  The thumb is also clawed.

 

7.     FORCED GRASPING TEST 

Specifically stroke radial ward with your fingers across the patientís palm causes a grasp reaction of the hand.

 

8.     KLEISTíS HOOKING SIGN 

Exert pressure with your hand against the patientís flexor surface of the fingertips.  A sudden reactive flexion of the fingers indicates the affected hand.

 

9.     KLIPPEL AND WEIL THUMB SIGN 

Ask the patient to flex their fingers.  Quickly extend the patients fingers with your hand.  A positive test is demonstrated by flexion and abduction of the patientís thumb.

 

10. LERIíS SIGN 

Absence of normal flexion of the elbow upon forceful passive flexion of the wrist and fingers. 

 

11. MAYERíS SIGN 

Ask the patient to supinate their hand.  Absence of adduction and opposition of the thumb upon passive forceful flexion of the proximal phalanges, especially of the third and fourth fingers, of the supinated hand.

 

12. SOUQUEíS SIGN 

In attempting to raise the paralyzed arm, the fingers spread out and remain separated.

 

13. STRUMPELLíS PRONATION SIGN 

Upon the patient flexing the forearm, the dorsum of the hand approaches the shoulder instead of the palm.

 

 LOWER EXTREMITIES

 

1.     ANKLE CLONUS 

The patient is seated or supine.  Place your stabilizing hand upper the patient popliteal space.  Forcibly and quickly dorsiflex the patientís foot.  A positive test demonstrates and continued rapid flexion and extension of the foot.  A rapidly exhaustible clonus may be normal.

 

2.     BABINSKIíS SIGN 

With the metal end of the reflex hammer, stimulate the plantar surface of the foot from the Calcaneus along the lateral aspect to the forefoot.  Seeing the big toe extend while the other toes plantar flex recognizes a positive test.  This would indicate an upper motor neuron lesion indicating brain pathology or trauma.  In the newborn, a positive test is normal.  Shapiro advices forcible flexing of the second to fifth toes while eliciting the Babinskiís response in the usual manner, for a more definitive test.

 

3.     CHADDOCKíS SIGN 

Babinski response obtained by the stroking of the lateral malleolus.

 

4.     CROSSES EXTENSION REFLEX 

Ask the patient to lie supine on the examining table.  Have the patient flex both legs.  Stimulate the sole of the foot, which causes extension of the contralateral leg.

 

5.     EXTENSOR THRUST 

Extension of a flexed lowed limb when the sole of the foot is forced upward.

 

6.     GONDA REFLEX 

Press one of the patientís toes downward and release it with a snap.  The reflex is an upward movement of the Big Toe.

 

7.     GORDONíS LEG SIGN 

Squeezing the patientís calf will elicit a Babinski like response.

 

8.     GASSET AND GAUSSEL SIGN 

Ask the patient to lie in the supine position.  The patient will be able to raise either leg separately but cannot raise both legs simultaneously.  If the paralyzed leg is raised, it will fall back heavily when the examiner raises the unaffected leg.

 

9.     HIRSCHBERGíS SIGN 

Stroke the inner border of the foot.  The reflex will cause adduction and internal rotation of the foot.

 

10. HOOVERíS SIGN 

With the alleged Hemiplegic patient in the recumbent position, place the palms of your hands directly beneath the patientís heels, while the patient is asked to pres down Pressure should be felt only from the heel of the non-paralyzed leg.  Next remove our hand from beneath the non-paralyzed heel and place it o the dorsum of their foot, and the patient is instructed to raise the healthy leg against this resistance.  If the patient has a true organic HEMIPLEGIA, the hand remaining beneath the heel of the paralyzed leg will feel no added pressure.  However, if the patient has a hysterical paralysis, the heel of the supposedly paralyzed leg will press down against the examinerís had as an attempt is made to raise the healthy leg.

 

11. HUNTINGTONíS SIGN 

Flexion at the hip, extension at the knee, and elevation of the affected weak lower extremity upon coughing and straining.

 

12. MARIE AND FOIX RETRACTION SIGN 

Upon the forcing of the patientís toes downward, the knee and hip are drawn into flexion (important test).

 

13. MANDEL-BECHTEREW SIGN 

Flexor movement of the four outer toes upon striking the dorsum of the foot over the cuboid bone.

 

14. NERIíS SIGN 

The patient is in the recumbent position.  Ask the patient to alternately raise one leg at a time.  The knee of the paralyzed side flexes, the other remaining straight.  Forward flexion of the trunk in the standing position causes the paretic lower lib to flex while the normal one remains straight.

 

15. OPPENHEIMíS SIGN 

Run the metal handle end of the reflex hammer along the crest of the tibia and the Tibialis anterior muscle.  A normal test indicates no reaction or the patient complains of pain.  A positive test extends the great toe while the other toes plantar flex.

 

16. PATELLAR CLONUS AKA TREPIDATION SIGN 

Forcibly depress the patella with a quick movement while the leg is in extension and relaxed.  A positive reflex is a rapid up and down movement.

  

KINESIOLOGY-PERIPHERAL NERVE INTEGRITY TESTING CORRELATED WITH MUSCULAR POWER 

Kinesiology is defined as that branch of biomechanics, which studies the science of movement.  In general, it is divided into two fields of study. 

1.     Osteokinematics, which is that branch of Kinesiology, which attempts to focus primarily on overall movement of bones, with little reference to their related joints.

2.     Arthrokinematic, which is that branch of Kinesiology, which attempt to focus on the intimate and delicate mechanics of joints. 

     Early you studied Kinesiology related to a motion exam testing the spine and determining the end feel of the joint and its subsequent status.  Know you will review the testing of the human muscle as a source for information about motor power, sensation, and segmental level of peripheral nerve involvement.  Any pathomechanical disorder affecting the cord and nerve roots specifically will produce manifestations in the extremities reflexive of the vertebral levels involved.  As stated and demonstrated in the Orthopedic Chapter, knowledgeable documentation and coordination of information about segmental level of peripheral nerve involvement comes in the form of noting intact dermatomes and reflexes.  Although these are also contained in a neurological examination, they are not exclusive to a neurological examination.  However, when we measure for atrophy, we were beginning to shift our orientation towards the neurological interpretation.  There we determined neurological level of involvement by understanding which nerve levels innervated the upper extremities vs. lower extremities and which level related to specific muscles.  Thus a muscle, which was atrophied, would give us a clue to a level of disc protrusion or irritation of nerve roots. 

     Obviously, it is known that pressure on nerve roots causes diminishing muscle strength.  In the Scientific Kinesiological examination you will be testing for this muscular weakness and coordinate the data to spinal level and neurological level of origin.  In the neurological portion of the examination always try to coordinate the motor, deep tendon reflex, and dermatome sensation.

 

MUSCLE TESTING 

     Muscle testing is an art and science.  Because of all the fraud associated with Muscle testing (i.e. magnet, vitamin, etc fraud), this science is best studied by physicians from a nerve level point of view.  Muscle test for nerve levels cervical fifth through the thoracic spine will follow.  In evaluating the cervicals, muscle testing of the shoulder has demonstrated excellent clinical data.  When muscle testing for cervical integrity the shoulder must be brought through nine motions:  Flexion, extension, abduction adduction, external rotation, internal rotation, scapular elevation (shoulder shrug), scapular retraction (position of attention), and shoulder protraction (reaching).  Testing will be classified according to joint motion and coordinated with the other objective findings. 

     Always note muscle power data with the 0-5 scales as follows: 

0=Non Contraction (Zero)

1=Flicker of contraction (Trace)

2=Sight power sufficient to move the joint (poor)

3=Power sufficient to move the joint against gravity (fair)

4=Power to move the joint against gravity plus added resistance (good)

5=Normal power with a full range of motion against gravity with full  resistance.  

 

KINESIOLOGICAL EXAMINATION OF THE CERVICAL SPINE MUSCULATURE: 

     In the cervical spine examination, have the patient seated.  You will begin by testing the intrinsic muscle in the neck and cervical spine as that may restrict motion when spastic and motor weakness, which can restrict or enhance cervical motion occur. 

 

FLEXION 

     Flexion of the cervical spine is primarily accomplished by the sternocleidomastoidius muscles acting bilaterally and innervated by the spinal accessory, or cranial XI nerve. 

     Stand in front of you patient.  Place your left hand upon the patientís sternal area.  Place your right resistance hand upon the patientís forehead with a broad palmer contact.  Ask the patient to forward flex his neck slowly, while you gradually increase the resistance until you determine patient overcome resistance.

 

EXTENSION 

     Extension of the cervical spine is primarily accomplished by the cervical paraspinal extensor (capitis, semispinalis, Splenius etc) and the Trapezius innervated by the spinal accessory or cranial XI nerve. 

     Stand behind you patient.  Place your stabilizing hand over the patientís posterocentral area of the thorax.  Place your resisting hand over the posterior occipital area. 

     Tell the patient to extend his/her neck slowly while you gradually increase the resistance until you determine patient overcome resistance.

 

LATERAL FLEXION 

     Lateral flexion of the cervical spine is primarily accomplished by the Scalenus anticus, Medius, and posticus, which have innervation, derived form the anterior primary divisions of the lower cervical nerves. 

     Stand to the side of the patient.  Place your stabilizing hand on the right shoulder to prevent substitution of shoulder elevation.  Then place the open palm of your resisting hand on the right side of the patientís head. 

     Ask the patient to laterally flex his head, while you gradually increase resistance until you determine the maximum patient overcome resistance.

 

ROTATION-LATERAL FLEXION 

     The contralateral sternocleidomastoidius muscle innervated by the signal accessory, XI cranial nerve, primarily accomplishes global rotation of the cervical spine. 

     Stand in front of the patient.  Place your stabilizing hand on his right shoulder to test the muscle for left global rotation.  Place your resisting hand along the left side of the patientsí mandible. 

     Ask the patient to rotate his head slowly, while you are gradually increase your pressure to determine maximal patient overcome resistance power.  Always check bilaterally for al applicable tests. 

     Whenever your examining the cervical spine with a Kinesiological examination it is mandatory to run the test you learned for the upper extremities to determine any pathology which may refer symptoms into the extremities including cord tumor, disc prolapse, stenosis, and brachial plexus pathologies.   

  

TEMPOROMANDIBULAR JOINT TESTING

OPENING THE MOUTH 

     The external pterygoid muscle primarily accomplishes opening the mouth with innervation derived by both the Trigeminal nerve-mandibular division, and the pterygoid branch. 

     Place your open palm of your resisting hand beneath the patientís jaw, and instruct him to open hi mouth, while you are gradually increase the pressure of resistance.  Determine the maximal patient overcome resistance power.  The patient should normally be able to over maximal resistance (patient should be able to open his mouth 3 finger girths) power.

 

CLOSING THE MOUTH 

     The Masseter muscle innervated by the Trigeminal nerve and Temporalis muscle innervated by the Trigeminal nerve primarily accomplishes closing the mouth.

 

EXAMINATION OF THE SHOULDER

 

FLEXION

      Flexion of the shoulder involves primarily the anterior portion of the deltoid and the Coracobrachialis muscles.  The deltoid is innervated by the Axillary nerve-C5 and the musculocutaneous nerve, C5-C6, innervates the Coracobrachialis.  In order to evaluate this nerve level the following muscle testing procedure is recommended. 

     When testing the patientís right shoulder stand behind the patient with your left hand upon their right Acromion.  This hand will be utilized for stabilization of the scapula and will palpate the anterior deltoid region while testing.  Grasp the biceps region of the left arm proximal to the elbow.  Bring the patientís elbow flexed to 90 degrees, and tell them to begin flexion of the shoulder.  As the patient begins flexion, increase your resistance carefully to determine the maximal resistance the patient can overcome.  Always test both shoulders to provide a bilateral comparison, and register your data accordingly. 

 

EXTENSION 

     Extension of the shoulder involves primarily the Latissimus dorsi, Teres major and posterior portion of the deltoid.  The Thoracodorsal nerve, C6, C7, C8, innervates the Latissimus dorsi; the Teres Major by the lower subscapular nerve, C5 and C6; and the Posterior portion of the deltoid innervated by the Axillary nerve, C5, C6. 

     Maintain the same position as for the flexion examination except that you move your right thenar eminence and palm over the posterior portion of the humorous.  Always try to palpate with the stabilization thumb for muscular tone; in this case posterior deltoid region.  Try to palpate the triceps with the resistance thumb. 

    Simply have the patient flex his elbow and slowly extend his arm posteriorly.  As the patient moves his shoulder into extension, increase pressure as you did in flexion testing, until you determine the maximum amount of resistance that he can overcome.

 

ABDUCTION: 

     Abduction of the shoulder involves primarily the mid portion of the deltoid and the Supraspinatous musculature.  The mid deltoid is innervated by the Axillary nerve, C5, C6 and the Supraspinatous is innervated by the Suprascapular never C5, C6. 

     Slightly adjust your position to the patient.  This will allow your stabilization hand to glide slightly lateral so you can palpate the mid portion with the deltoid.  Also, move your resistance hand slightly lateral so your palm contacts the lateral Epicondyle area. 

     Have the patient abduct his arm gradually as you increase resistance pressure until you determine the maximum resistance the patient can overcome.

 

ADDUCTION 

     Adduction of the shoulder involves primarily the Pectoralis major and the Latissimus dorsi musculature.  The Pectoralis major is innervated by the medial and lateral anterior thoracic nerve, C5, C6, C7, C8, T1 and the Latissimus dorsi is innervated by the Thoracodorsal nerve, C6, C7, and C8. 

     Move your stabilization hand anteroinferiorly upon the Acromion so that palpation of the Pectoralis major will be possible. 

     Have your patient adduct his arm while your gradually increase the degree of resistance, until determination of maximal resistance that the patient can overcome is made.  Record you data.

 

EXTERNAL ROTATION 

     External Rotation of the shoulder involves primarily the Infraspinatous muscle innervated by the Suprascapular nerve, C5 and C6 and the Teres minor muscle innervated by a branch of the Axillary nerve. C5. 

     Stand directly lateral to the patient and have the patient bend his elbow to 90 degrees. Stabilize his/her flexed elbow against his waist with his forearm in a neutral position.  Grasp his wrist with your right resistance hand. 

     Ask your patient to move his arm in a rotational manner outward while you gradually increase the resistance until determination of maximal resistance the patient can overcome is recorded. 

 

INTERNAL ROTATION 

     Internal Rotation of the shoulder involves primarily the following musculature and corresponding innervation. 

1.     Pectoralis Major Innervated by the medial and lateral anterior cervicothoracic nerves C5, C6, C7, C8, and T1.

2.     Latissimus Dorsi innervated by the Thoracodorsal nerve, C6, C7 and C8

3.     Subscapular innervation by the upper and lower subscapular nerves, C5 and C6

4.     Teres major innervated by the lower subscapular nerve C5 and C6. 

     The stabilization hand and your body position remain the same.  Move your resistance hand so that your fingers wrap around the wrist and the palm over the radial styloid process.

      Ask your patient to gradually move (rotate) their arm in front of their body while you carefully increase resistance against his wrist.  Note the maximal resistance factor.

 

SCAPULAR ELEVATION 

     Scapular Elevation of the shoulder involves primarily the Trapezius innervated by the spinal accessory nerve, also know as the XI cranial nerve; and the Levator Scapulae innervated by branches of C4 and C4 and in many cases branches from the dorsal scapular nerve, C5. 

     Move behind you patient and place your hands directly upon each Acromion.  Make sure that you have your thumb posteriorly placed over the trapezius muscle for palpation during the test. 

     Ask the patient to shrug their shoulder, and gradually increase downward pressure through your resistance hands. Note any difference in the elevation of the two sides.  Scapular elevators normally overcome your resistance.  Records your data.

  

SCAPULAR PROTRACTION

       Scapular Protraction of the shoulder involves primarily the Serratus anterior muscle innervated by the Long Thoracic Nerve, C5, C6, and C7.  Scapular protraction refers to the motion of the scapula during the last few degrees of reaching.  Here scapula moves Anteriorly on the thorax. 

     Remain standing posterolaterally to the patient.  Have the patient flex their arm 90 degrees remaining parallel to the floor.  Cup his elbow with your resistance hand sliding your stabilizing hand over the patientís spine preventing substitution or recruitment of the trunk rotation for the shoulder protraction. 

Ask the patient to move his bent arm forward as if he were reaching forward with his elbow and gradually increase your resistance to this anterior reaching motion, until the maximum resistance they can overcome occurs.  During the testing of shoulder protraction, always note the motion of the scapulae for any winging which indicates weakness of the Serratus anterior muscle.  This may also be noted by observing the patient do push-ups or pushes against a door.  Record your data.

 

SCAPULAR RETRACTION

      Scapular retraction of the shoulder involves primarily the Rhomboid major innervated by the dorsal scapular nerve C5 and the Rhomboid minor innervated by the dorsal scapular nerve, C5. 

     Now move to the front and face the patients.  Place your palms just anterior to the Acromion and the fingers reaching around the lateral aspect of the shoulder over the medial deltoid and behind the shoulders.  Have the patient throw him or herself into a position of attention (as in the military).  Now slowly apply force with your fingers trying to bend the shoulders forward around your thumbs without digging your fingers into their musculature.

 

KINESIOLOGICAL TESTING OF THE ELBOW

 

FLEXION

      Flexion of the elbow involves primarily the Brachialis innervated by the musculocutaneous nerve, C5, C6 and the Biceps when the forearm is supinated innervated by the musculocutaneous nerve, C5, C6. 

     Remain standing in the front of the patient after scapular retraction testing.  Grasp the patientís right arm just proximal to the joint with your left stabilizing hand.  Grasp the patientís right forearmís palmar surface just proximal to the carpal bones. 

     Ask the patient to flex his arm slowly.  When his arm flexion approaches 45 degrees, begin to increase resistance until the maximum resistance the patient can overcome is noted.  Always test bilaterally and record the date. 

 

EXTENSION 

     Extension of the elbow involves primarily the Triceps innervated by the radial nerve. 

     Remain the same initial position for testing flexion.  Have the patient extend their arm slowly from the flexed position.  Before reaching a position of approximately 90 degrees, gradually increase resistance to determine overcome resistance power.

 

SUPINATION 

     Supination of the elbow involves primarily the Biceps innervated by the musculocutaneous nerve, C5 and C6 and the Supinator muscle innervated by the radial nerve, C6. 

     With your left hand, grasp the patientís right forearm with your thenar eminence on the head of their radius while rapping your fingers around the posterior aspect of the ulna. 

     Have the patient initiate forearm Supination from a Pronation position.  Ask them to begin Supination as you gradually increase your distance until you determine patient overcome resistance and record you findings.

 

PRONATION 

     Pronation of the elbow involves primarily the Pronator Teres muscle innervated by the median nerve, C6 and the Pronator Quadratus muscle innervated by the anterior interosseous branch of the median nerve, C8 and T1. 

     Grasp the patientís forearm with your right hand opposite the position you maintained for testing Supination with your thenar eminence against his volar surface. 

    Have the patient initiate forearm Pronation from a Supination posture.  Ask them to begin Pronation as you gradually increase your resistance until you determine patient overcome resistance force and note degree. 

 

KINESIOLOGICAL TESTING OF THE WRIST AND HAND 

WRIST

Wrist extension Ė C6 

The following group of muscles primarily accomplishes extension of the wrist.

1.     Extensor Carpi radialis Brevis innervated by the radial nerve C6 and perhaps some C7.

2.     Extensor Carpi radialis longus innervated by the radial nerve C6 and perhaps some C7.

3.     Extensor Carpi ulnaris innervated by the radial nerve, C7. 

     Place your left stabilizing hand upon the wrist of the patientís right wrist rapping your fingers under their volar aspect of the wrist.  Ask the patient to extend his wrist fully.  Place the palmar aspect of your right hand over his fist, exert force, and try to take his wrist out of the extended position.  Normal power data would correlate with an inability to move the patientís wrist out of its position.

 

WRIST FLEXION C7 

      The primary flexors of the wrist are the flexor Carpi radialis muscle innervated by the median nerve, C7 and the flexor Carpi ulnaris muscle innervated by the ulnar nerve, C8 and perhaps some T1. 

     Keep your stabilization hand in the same position as extension testing.  Ask the patient to flex their wrist fully while maintaining a closed fist.  Place your resistance hand over their fist, ask the patient to resist and attempt to translate the wrist out of flexion. 

Wrist Supination and Pronation were demonstrated in the elbow section above. 

 

FINGER TESTING

 

FINGER EXTENSION Ė C7 

     The following group of muscles primarily accomplishes extension of the fingers. 

1.     Extensor Digitorum Communis innervated by the radial nerve, C7

2.     Extensor Indicis muscle innervated by the radial nerve, C7

3.     Extensor Digiti Minimi muscle innervated by the radial nerve C7 

     Have the patient extend their metacarpophalangeal joints, while leaving their proximal interphalangeal joints in flexion.  Slide your stabilizing hand so that your thumb grasps the radial base wrapping your fingers around the volar surface of the wrist.  Place your resistance hand over the dorsal aspect of the fingers.  Attempt top force the phalanges into extension while the patient resists.

 

FINGER FLEXION Ė C8 

     The following group of muscles primarily accomplishes flexion of the fingers.

1.     Flexor Digitorum profundus muscle innervated by the ulnar nerve, C8 and T1 with further innervation from the anterior branch of the median nerve (Distal Interphalangeal Joints).

2.     Flexor Digitorum Superficialis muscle innervate by the median nerve C7, C8 and T1 (Proximal Interphalangeal Joint).

3.     Lumbricals are flexors of the metacarpophalangeal joint divided into medial two Lumbricals innervated by the ulnar nerve, C8 and the Lateral two Lumbricals innervated by the e median nerve, C7. 

     Ask the patient to flex his fingers into a loose fist.  Then flex and interlock your left hand into his right hand while still maintaining the stabilization hand.  Attempt to pull his fingers out of flexion.  Note any joints, which failed to maintain finger flexion.  Normal study would find all the joints remaining in flexion.

 

FINGER ADDUCTION Ė T1 

     Finger Adduction is primarily accomplished with the palmar Interossei muscles innervated by the ulnar nerve C8 and T1 levels. 

     Ask the patient to keep their extended fingers together while you attempt to pull the apart.  Generally, most knowledgeable kinesiologists test the fingers in pairs.  Begin with the index and middle, followed by the middle and ring fingers, and last the right and little fingers.

 

ABDUCTION Ė T1 

     Abduction of the fingers if primarily accomplished by the dorsal Interossei muscles innervated by the C8 and T1 and the Abductor Digiti Minimi muscles innervated by the ulnar nerve C8 and T1. 

     Ask the patient to abduct his extended fingers or spread hi fingers and hold.  The physician tryís to force his fingers together.

 

THUMB TESTING 

EXTENSION 

     Extension of the thumb is primarily accomplished in the following manner: 

     The Extensor pollicis Brevis extends over the metacarpophalangeal joint and is innervated by the radial nerve, C7, the Extensor Pollicis Longus Muscle extends the interphalangeal joint innervated by the radial nerve, C7. 

     Ask the patient to extend his thumb.  Attempt to push the thumb into flexion.  Check for weakness and correlated with the thumb abductors which can cause thumb extension.

 

FLEXION 

     The Flexor Pollicis Brevis with its dual innervation of medial portion by the ulnar nerve, C8 and the lateral portion by the median nerve, C6 and C7 act as flexors of the metacarpophalangeal joint.  The Flexor Pollicis Longus innervated by the median nerve, C8 and T1 would flex the metacarpophalangeal joint. 

     Ask the patient to touch his hypothenar eminence with his thumb.  Grasp your thumb around the patients fully flexed thumb and attempt to pull his thumb out of flexion.  Note power and correlate bilaterally.

 

ABDUCTION 

     Abduction of the thumb is primarily accomplished by the Abductor Pollicis Longus innervated by the radial nerve, C7 and the Abductor Pollicis Muscle innervated by the median nerve, C6 and C7. 

     Maintain your stabilizing hand by placing your thumb over his Pisiform and rapping your finger around his wrist.  Ask the patient to abduct his thumb completely, while your attempt to push the thumb back into the palm.  Correlate with thumb extensor, which can be secondarily substituted to accomplish thumb abduction.

 

ADDUCTION 

     Adduction of the thumb is primarily accomplished by the Adductor Pollicis (Oblique and Transverses) innervated by the ulnar nerve, C8.  Maintain your stabilization hand as you did in the abduction test.  While you hold the patientís thumb, ask the patient to adduct it, and gradually increase resistance to determine patient overcome resistance pressure.

 

PINCH MECHANISM OF THE THUMB AND INDEX FINGER 

     The pinch mechanism demonstrates the integrity of long flexors and extensors, which stabilize the interphalangeal, metacarpophalangeal, and carpometacarpal joints.  The Interossei and Lumbrical muscles must be intact to assist this mechanism. 

     Ask the patient to touch his thumb and index finger together.  Hook your index finger at the junction of the two fingers and attempt to pull them apart.  A normal study would find that you would not be able to pull the fingers apart.

 

THUMB AND LITTLE FINGER OPPOSITION 

     The Opponens Pollicis muscle innervated by the median nerve primarily accomplishes this motion, C6 and C7 and the Opponens Digiti Minimi innervated by the ulnar nerve, C8. 

     Ask the patient to touch the tips of his thumb and little finger together.  Grasp the patientís thenar eminence with one hand and his hypothenar eminence with your other, and try to pull his thumb and little finger apart.

 

EXAMINATION OF THE HIP AND PELVIS PRIMARY MOVERS 

     As with the previous test, coordinate the motion integrity with motor power and nerve level.

HIP FLEXION 

     The Iliopsoas muscle innervated by L2, 3 and 3, primarily accomplishes flexion of the hip and pelvis.   

     Have the patient sit on the edge of the examining table.  The stabilization hand is placed over the iliac crest.  Have the patient raise their thigh from the table.  Place your resistance hand upon the distal end of the thigh and have the patient raise their thigh further while you exert pressure.  Determine the MOR (maximum overcome resistance) and record your data.  Repeat the test upon the other thigh. 

 

EXTENSION 

   Extension of the hip and pelvis is primarily accomplished by the Gluteus Maximus innervated by the inferior Gluteal Nerve, S1. 

     Have the patient lie prone on the exam table and have the patient flex their knee to relax the hamstring muscle.  Place your forearm upon the iliac crests resting your hand upon the gluteus Maximus and palpate as you test the muscle.  Place our resistance hand over the posterior thigh region.  Have the patient raise their thigh from the table while you exert pressure down on the posterior thigh region just above the knee.  Record the patients MOR and test the opposite hip.

 

ABDUCTION 

     Abduction of the hip is primarily accomplished by the Gluteus Medius innervated by the Superior Gluteal nerve, L5. 

     Have the patient lie on their side.  Place your stabilizing hand upon the patientís iliac crest.  Ask the patient to abduct their leg.  Place your resistance hand over the lateral aspect of the leg and while the patient is resisting attempt to push the legs together.  Repeat the test upon the opposite hip and record data.

 

ADDUCTION 

     The Adductor Longus muscle innervated by the Obturator Nerve, L2, and 3,4 primarily accomplishes adduction of the hip. 

     Have the patient lie supine upon the table.  Ask the patient to abduct their legs while you exert pressure on the medial aspects of both legs grasping them just above the ankles.  Record your data.

 

KINESIOLOGICAL EXAMINATION OF THE KNEE 

EXTENSION

     Extension of the knee is primarily accomplished by the Quadriceps muscle innervated by the Femoral nerve, L2, 3, and 4. 

     Have the patient sit near the edge of the table.  Place your stabilizing hand just above the patientís knee.  Ask the patient to fully extend their knee.  With the knee fully extended, exert pressure just above the ankle joint.  Record data and test the other knee.

 

FLEXION 

     The HamstrIngs muscles primarily accomplish flexion of the knee.

1.     Semimembranosus innvrvated by the Tibial portion of the sciatic nerve L5.

2.     Semitendinosus innervated by the Tibial portion of the sciatic nerve L5.

3.     Biceps Femoris muscle innervated by the Tibial portion of the sciatic nerve S1. 

     Have the patient lie prone on the exam table.  Pace your stabilizing hand over the thigh just above the knee.  Ask the patient to flex their knee while you resist this motion by containing just above the ankle joint and exerting pressure.  T specifically test the biceps Femoris muscle externally rotate the patientís leg and test.  To test the Semimembranosus and Semitendinosus muscles more specifically internally rotate the leg and test.  Record data and test the opposite extremity. 

     Internal and External Rotation will not be tested as isolating the specific muscle which would cause these motions cannot be accomplished specifically.  It must be noted however that their muscle power has been tested during the flexion and extension tests.

 

KINESIOLOGICAL TESTING FOR THE FOOT AND ANKLE 

     The Kinesiological examination for the foot and ankle is divided into testing Dorsiflexion and plantar flexion.  Some of the muscles, which cause these motions, also cause inversion and Eversion.  The tendons in front of the malleoli primarily cause Dorsiflexion of the foot and this behind the malleoli yield plantar flexion. 

     The following muscles primarily accomplish Dorsiflexion of the foot.

1.     Tibialis Anterior innervated by the deep Peroneal never L4 (L5)

2.     Extensor Hallucis Longus innervated by the deep Peroneal nerve, L5.

3.     Extensor Digitorum Longus innervated by the deep Peroneal nerve, L5. 

     It must be noted that any Pathomechanics, which prevent proper nerve function, will result in foot drop and this nerve level can be coordinated by the following examinations. 

 

TIBIALIS ANTERIOR 

     Have the patient sit on the edge of the examination table.  Grasp the patientís lower leg with your stabilizing hand.  Wrap you resistance hand about the dorsum of the foot with your fingers under the foot.  Ask the patient to dorsiflex and invert his foot.  Try to plantar flex and evert his foot and record data.  Test the opposite foot. 

EXTENSOR HALLUCIS LONGUS 

     Have the patient sit on the edge of the table.  Grasp the patientís Calcaneus and stabilize the foot.  Grasp the big toe with your thumb over the nail area with your fingers under the foot.  Ask the patient to dorsiflex their toe and you offer resistance and attempt to push the toe down.  Be sure your resistance contact is distal to the interphalangeal joint.  If your contact is across the interphalangeal joint, you may also be testing the Extensor Hallucis Brevis. 

EXTENSOR DIGITORUM LONGUS 

     Have the patient sit on the edge of the table.  The stabilization hand is again upon the Calcaneus.  Have the patient extend their toes.  Place your thumb across the toes and attempt to plantar flex the patientís toes.  Record our data and test the other foot.  A normal study would present unyielding toes.

 

PLANTAR FLEXION 

     The following muscles primarily accomplish plantar Flexion of the foot:

1.     Peroneus Longus and Brevis innervated by the superficial Peroneal nerve, S1.

2.     Gastrocnemius and Soleus innervated by he Tibial nerve, S1, S2.

3.     Tibialis Posterior innervated by the Tibial nerve, L5.

4.     Flexor Digitorum Longus innervated by the Tibial nerve, L5.

5.     Flexor Hallucis Longus innervated by the Tibial nerve, L5.  

PERONEUS LONGUS AND BREVIS 

     Ask the patient to sit upon the edge of the table.  Stabilize the Calcaneus with one hand.  Place your resistance hand so that your thumb rests against the fifth metatarsal head.  Have the patient plantar flex and evert their foot while you oppose plantar flexion and Eversion.  Record data and test the opposite foot. 

GASTROCNEMIUS AND SOLEUS 

     Ask the patient to lie in the supine position.  Grasp the patientís foot and place it in the neutral position.  Ask the patient to plantar flex his foot while you offer resistance.  Record the data (This primarily records Soleus data). 

FLEXOR HALLUCIS LONGUS 

     Ask the patient to sit on the edge of the table.  Again, stabilize the Calcaneus.  Instruct the patient to bend his great toe, while you resist the plantar flexion.  Perform the test on the opposite foot and compare relative power. 

TIBIALIS POSTERIOR 

     Ask the patient to sit on the edge of the table while you stabilize the Calcaneus.  Have the patient plantar flex his foot and invert his foot while your offer resistance.  Record the data and compare bilaterally.  Also, compare muscle power with other regional muscles, as they should be in balance.

EXAMINATION OF THE LUMBAR SPINE 

     The Kinesiological examination of the Lumbar spine would include testing the musculature associated with a nerve level in question.  Thus the tests you learned in the hip, pelvis and lower extremities would be utilized to determine nerve level integrity.  When ever you examine the cervical spine or lumbar spine you coordinate the Kinesiological testing you have performed with the nerve level.  At the same time you test for sensation 

by Scott D. Neff, DC DABCO CFE DABFE FFABS FFAAJTS, 2010 Graduate Antigua School of Medicine, West Indies created for the medical students of our world as well as a dedication to the people of America and our world. ©

"Why does this magnificent applied science which saves work and makes life easier, bring us little happiness? The simple answer runs, because we have not yet learned to make sensible use of it." Albert Einstein 1931

© & TM 1998 American Academy for Justice Through Science. All rights reserved.

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