The second session, titled Neuromuscular Exam, Motor Examination, is presented by Ms. Connie Wolford and Dr. Sarada Sakamori. Ms. Wolford is an AANP board-certified nurse practitioner who has worked with the Stanford University neuromuscular team for the last 11 years. Dr. Sakamori is clinical assistant professor of neurology and neurological sciences at Stanford University. Hello, I'm Connie Wolford, nurse practitioner with the neuromuscular clinic at Stanford. Welcome to the AANEM education series for advanced practice providers. And the session today will focus on the neuromuscular motor examination. The purpose of the neuromuscular motor exam is to determine the presence of motor deficits and also patterns of deficits and types of deficit. Weakness can be identified as indicating pathology of upper motor neuron systems, lower motor neuron, or both systems. Of course, upper motor neurons originate in the cerebral cortex and travel down to the brainstem or spinal cord, while the lower motor neurons begin in the spinal cord and go on to innervate muscles throughout the body. Upper motor neuron involvement interferes with synergistic functions of multiple muscle groups at the same time, whereas lower motor neuron involvement may express as weakness of a select group of muscles. With upper motor neuron involvement, you may have hyperreflexia, spasticity, weakness. You may see that flexors are stronger than extensors that should be in the upper extremities, and the opposite is true in the lower extremities, so slow, clumsy movements that produce weakness. And then with lower motor neuron signs, weakness, loss of function, atrophy, fasciculations, where there's actual weakness leading to greater weakness. The first component of the motor exam is observation. If at all possible, take the time to have your patient in a gown so you can observe muscle bulk and look for atrophy versus hypertrophy. Patterns of muscle wasting can lead to diagnosis or hypertrophy. For example, enlargement of calf muscles can lead you down, can be very characteristic of Duchenne and Becker muscular dystrophy. You want to look for involuntary movements such as fasciculations or tremors like you might see with ALS or Parkinson's disease. You want to observe for deformities such as pes cavus, hypo or kyphoscoliosis, scapular winging as seen in the picture here would certainly be consistent with FSHD. This is something you might not observe if the patient is not in a gown. And then, of course, you can observe for cutaneous findings such as rashes you might see with dermatomyositis. Palpation, percussion, and manipulation are the next part of the motor exam. You want to look at the muscle tone, spasticity, hypotonia, even cogwheeling rigidity. Of course, increased upper tone would be consistent with the upper motor neuron lesion. Percussing and manipulating techniques can allow you to observe myotonia or delayed relaxation of the muscle after contraction. Unfortunately, this is not a video, but you can see with the reflex hammer, the contraction of the muscle in the forearm here was sustained with myotonia. And then, palpating pain is less useful, but you may detect tenderness with some of the metabolic myopathies. Strength testing is the most important part of a motor exam, and strength can be tested in using isometric manual testing as well as functional testing. Functional testing such as ability to hop on one foot or having a patient be able to get up out of a seated position may be very useful in folks that are particularly frail or very strong or if pain is involved in the action. Muscles should typically be tested against gravity in a fully contracted position, and it's a good approach to go systematically testing one limb and comparing to the other, usually from head to toe and proximal to distal order. The Medical Research Council Scale, or MRC, is the most widely used strength grading system. With zero being no contraction at all, one, a flicker or a trace of contraction that is either seen or felt in the muscle, two, active movement with gravity eliminated, three is active movement against gravity, so full range of motion against gravity, four, active movement against gravity and resistance, and then five, of course, is full strength. Keep in mind, quantitative testing is also useful in tracking changes over time, for example, responses to therapy, and this may be done with a six-minute walk test, time to up and go, or handheld dynamometry. If you have a physical therapist that works in your clinic or with your program, they can be very useful in performing those assessments. There's a great deal of variability with a degree of strength testing with the MRC, particularly in the four score, so the modified MRC was developed, and it's often used to better define the degrees of weakness. There are limitations to both MRC and MMRC. Scoring is subjective based on the examiner's perception. It does not account for variability in the degree of resistance that the examiners use, and it does not account for pain or poor effort on the patient's part. There are many, many muscles that can be tested during a strength exam, and these are some of the common muscles that are tested, but the complaints will dictate which muscles are tested. These are some of the most common muscles. Keys to strength examination, number one, observe. Watch the contracting muscles. Know the expected strength of your muscle. We should not be able to overcome large muscle groups like quadriceps. Isolate the action. If you can test one joint at a time and use leverage, so use one hand to support and then allow the other one, while allowing the joint to flex. If you can't do that, you can test the other joint fully, go through a range of motion with contraction of the muscle. And then a sustained effort should be used for more than a second. If you're trying to identify fatigable weakness, as with myasthenia gravis, you might actually have the patient sustain a contraction against gravity, either with or without resistance, until they fatigue and then repeat after a rest period. Coordination is another factor of the motor examination. Rapid, rhythmic, alternating movements of the upper limbs and lower limbs can be used to identify abnormalities in coordination. This can be tapping the thumb against the index finger, pronation and supination of the palms in a rapid fashion, tapping toes on the floor, tapping heel on the opposite knee, as well as finger to nose with eyes open and closed, and heel to shim. Reflexes, station, and gait will be covered in another session. Now we're going to move on to a demonstration of the neuromuscular motor exam performed by Dr. Sarada Sakamori. Hi, I'm Sarada Sakamori. I'm a neuromuscular neurologist, and now we're going to demonstrate how to perform the motor exam. In this case, we have a healthy participant, but we'll talk about some strategies for identifying subtle pathology. So as Connie mentioned in her talk, we'll start by looking at the tone and bulk, but what I'll do now is demonstrate actually how to grade the, or how to engage the patient in the strength exam. First, we'll look at her strength in her neck flexion and extension. Ideally, she would be laying supine or prone for this, but when the patient is seated, you can have them bring their chin down to their chest, put your hand on their forehead, and stabilize with your other hand on their back. Push against my hand. Very good, and now we'll have her look up at the ceiling to check neck extension. Again, I'm stabilizing her a little bit, and push backwards against my hand. Go, go, go, and relax. Now we'll look at strength in the sternocleidomastoid. Remember that when she turns to the right, she's engaging the muscle on the left. So go ahead and turn your head that way. We'll start by inspecting the muscle. Don't let me move your head, and we're looking at the muscle bulk, and now the same thing on the other side. We're looking at the muscle bulk here. Don't let me move your head. All right, so again, as Connie mentioned, we'll look at bulk, tone, pronator drift, rapid movements, and so on, but again, we're focusing on strength. So now we'll look at shoulder abduction. In a patient who's super, super strong, you might check each arm individually so that you can push down with both hands. So go ahead and push, but in most patients, you'll do both sides at the same time. Go ahead and push up. Don't let me push down, and that's so that they don't end up tilting one way or another. You can put your arms like this to check elbow flexion, typically mediated by the bicep. You can stabilize by putting one arm proximally and the other over the limb. In order to get the most advantage for ourselves, we can put our hand more distally so that the lever arm is longer. If we put our hand proximally, we're not getting the maximum advantage in testing. If the patient is very, very weak, you can give them the advantage by having them start a little bit more flexed. If the patient is extremely strong, start with them fully extended. You can even use two hands to resist. You can stand up from the chair, plant your feet, and this is what I did this morning on my patient who's an Ironman athlete. So now you can push up against me, and so that's how you can give yourself the advantage. First triceps testing is the same idea. So for typical cases, I start with the arm at about 90 degrees, but if I want to give myself the advantage, I'll start with the patient more flexed and have them push against me here while I'm bracing myself against their shoulder. But otherwise, we can start at the 90 degree level and do the same thing. For each muscle, it's good to stabilize yourself with one hand on the proximal segment of the limb. That way the patient is not rocking and tilting in space, and that's especially important when you're testing distally. So if we look now at wrist extension or wrist flexion, if she's performing wrist extension and her arm is like this, it's a little hard to isolate what she's doing. So if you find the patient is very anxious and tense and curled up, just try to help them relax their arm and focus on just keeping their wrist extended and elevated. Again, you can hold the proximal element, which is the forearm, and then push against the wrist as opposed to just having her free floating in space where her arm might bounce around a little bit. I want to come closer, so you can see the hand specifically. Thank you. For wrist extension, I think it's more comfortable for patients to start with their arm supinated as opposed to pronated, but some people test wrist flexion like this. The other option is to test wrist flexion like this. And again, try to stabilize their forearm so they can just focus on flexing their wrist so they don't end up completely curled up. That makes testing a lot more challenging and less accurate. All right, now we can look at finger extension. So extending at the knuckle, the MCP joint, we're holding the hand, the palm of the hand, and we're providing resistance. Everybody has their own way of doing this. You can try to use your own finger extensors. You can try to kind of slice against the fingers, but the important thing is to ensure the patient is engaged. So with all of these muscles, don't do a quick test and leave. Sometimes you have to maintain pressure so that the person can fully engage, especially if they have Parkinsonism, spasticity, pain. It can take a moment for them to build up their strength. On the other hand, if they have pain, we can coach them. We can say, Connie, push as hard as you can for five seconds. Go, go, go, go, go, and then she might give way, but at least we got a feel for her best strength. All right, now we'll take a look at the deep finger flexors that flex at the interphalangeal joints of the fingers. So we'll start with the flexor pollicis longus that flexes the thumb. So I'm holding the base of her thumb, I'm having her bend, and I'm using my thumb against it. Be really careful if the person has arthritis, ask beforehand if there's pain limitation. In a patient with inclusion body myositis, we might see weakness of these deep finger flexors. So what we often do is stabilize by holding at the second phalanx, the second segment of the finger, and having them claw or curl their finger. That way we're isolating the deep finger flexors that bend at this joint, as opposed to the superficial finger flexors that bend at the proximal joint. Finally, we'll take a look at some of the small hand intrinsic muscles. We'll look at the bulk of the flexor first dorsal interosseus and the abductor digiti minimi. We can also see the abductor digiti minimi bulk over here. And we'll look at the abductor pollicis brevis that helps move the thumb. Spread your fingers wide apart. I'm going to use my finger abductor against hers to gauge the strength of this abductor digiti minimi. And same thing over here to gauge the strength of her first dorsal interosseus. And turn your hand over. To gauge the strength of the abductor pollicis brevis, we take the thumb and sort of center it over the palm. That way we know we're engaging the correct muscle here. We don't want the thumb out to the side. We want it centered over the palm. Look at the bulk of muscle here and just slide your finger up. And that's where you can provide resistance. So we're preventing her from letting her thumb fall down towards her hand. All right, now we'll go on to the lower extremity exam. Again, ideally, if you're checking proximal muscle strength, the patient should be prone for neck flexion extension. Same is true for hip flexion extension. But realistically, we're often doing it in a seated position. For hip flexion, it's okay to let the patient stabilize themselves. So why don't you get your hands here. And actually, our videographer can stand here and you'll be able to see a little bit more. So we'll have her check one hip at a time. Can you lift your leg up and keep it there? Don't let me push it down. And again, you might have to give people a moment to engage this muscle. Also, the older we are, oftentimes the more deconditioned we are in this location. So sometimes, appropriately, someone may not seem as strong, but you have to grade them against others of their age group. Hip extension, sometimes people put their hand under the leg and have the patient push down. It's often not very accurate. If you really want to test it, it's best done with the patient laying prone on the bed. For hip abduction, we usually will check both legs at the same time. I'll have you push your knees out against my hands. Go, go, go, go, go. And relax. And again, if the patient is laying in lateral decubitus position on their side, they can do that hip abduction exercise and then you'll get an even more accurate measurement. For hip abduction, bringing the knees together, I usually, instead of putting my left hand on their right knee and right hand on their left knee, I'll usually cross hands because I feel like I can get a bit more strength that way. So go ahead and push your knees together. Go, go, go. And relax. Good. For knee extension, again, if we want to give ourselves the advantage, we can start with the patient with their knee flex. But before you start, always look to see if they can pass or if they can get through the full range of motion on their own. Very good. Sometimes patients can only get this far and they can provide good resistance, but they don't have the strength to make the full range of motion. So check that in advance. But don't check knee extension with their knee fully locked because then it can be much harder to overcome their strength. So go ahead and push against my hand here. Good. For knee flexion, we're going to have her pull her foot under the bed. Go ahead and pull underneath. Go, go, go. And again, when possible, try to use your other hand to stabilize the leg so that the patient can just focus on the movement you want. For ankle movements, I like to do them with the leg propped up on a chair or a bench. That way I can really see what I'm doing. I'm going to take off your socks. Okay. All right. So we'll start by looking at range of motion passively and looking for any pain that will limit the testing. For dorsiflexion, I'll have you keep your foot like this. We're inspecting the bulk of the muscle. And people are very strong, so you can actually put two hands and pull them if you have to. And that's how you can find weakness in a very strong individual as opposed to just using your wrist. You have to really use your biceps to overcome this muscle. We can look at the extensor digitorum brevis, which is small muscle on the dorsum of the foot. Can you bring your toes up? Good. And you'll see that muscle contract. And it's important to inspect that muscle bulk, especially in someone with a neuropathy or a lumbar radiculopathy. And relax. You can curl your toes down. That will give us insight into the plantar or tibial nerve function. One challenge is if someone has a lot of numbness, they have a lot of trouble curling their toes. So keep that in mind. And you can relax. Another good way to check dorsiflexion and plantar flexion strength is to have the patient walk on their toes or on their heels. So we can do that now. All right. So now if you'll turn around, please. We can see that. Go ahead and get on your toes. We can see she's activating her calves. And relax. And now we'll have you turn once more. If the patient is very strong but you suspect mild weakness, you can have them hold on to a countertop and do single calf raises. And if they're able to do it on one leg but not the other, that's a clue. You might also measure the circumference of their calf. You might take a picture of each calf to compare. And then you can turn back towards us. A great test for tibialis anterior or dorsiflexion strength is walking on your heels. And look at the height that she gets. Some patients can only bring their foot up a little bit. And that's a sign of some weakness in this region. All right. Well, that's a brief overview of the motor exam. And thank you very much to our volunteer. Thank you. All right. So, hi, I'm Connie Wolford. Welcome to our AANEM Advanced Practice Provider webinar series. I hope that you have found it useful. And so far, we're only on our second session today. But hopefully, you were able to gain some pearls from our motor examination. I'm sure a lot of it was refresher for you. But maybe you gained some pearls of wisdom as well. I am happy to answer any questions you have about the motor exam or if you want to ask, happy to answer questions about my practice as a nurse practitioner in the neuromuscular program as well. Yeah, so the question is, I've been trained by several board-certified neurologists and there's disagreement between them on documenting 4- versus 4 when documenting motor exam. How do you document? I think the most important thing to remember is it's very subjective. You could have, you know, two board-certified neurologists assessing a patient and likely have different scores from each. So the thing that's most important, I think, is that you have some consistency in who the examiner is. And then, you know, 4-, I'd say, your question as to 4- versus 4. So 4, obviously, is when the patient is able to provide some resistance against gravity and against you with confrontation. And then degree of weakness, if it feels like they're slightly weak or they're really, really weak, I might give them a 4-. That's not a very objective assessment tool. It's not a great answer either, but that's what we have. I have a question here, what strategies do you use with giveaway weakness? So what strategies do you use with giveaway weakness? I think that you may be, I'm not sure if you're referring to maybe a patient that you suspect is malingering or maybe has a somatoform disease, but I think that you can certainly incorporate some functional testing. So if you found maybe some giveaway weakness, for example, in hip flexion, you could include a functional, just after the exam, maybe have them rise from a seated position and move over to another seat in the room. And then obviously watch to see if they have, what kind of effort they have to expend to get out of the chair. So somebody with some true hip flexor weakness will likely have difficulty getting out of the chair. They might expend a little more effort. They might use arms to help push off. They may even have a modified Gowers maneuver. If they jump out of the chair and move right over to the next task, then that's a good indicator that the weakness, there might not be certainly four plus weakness. One thing I would caution about using kind of functional testing for a motor exam is that many patients will have or may have adopted kind of some adaptive or compensatory strategies. So you should be cognizant of those if you're using functional testing for your exam. Maybe there's hand weakness and you're going to have the patient grip a pen and write their name or something. So they may be able to very well do it, but it may be that they are gripping the pen using different muscle groups or using a different grip than they would have traditionally used. I would really be curious to know, we don't have a polling capability here, but I'm curious to know how many of our APPs joining us today are examining patients in clinic and how many of you maybe practice independently with folks and in what capacity you practice. So if anyone feels comfortable adding that to the chat, I can tell you with my, the way I practice with the Stanford Neuromuscular Group is independently and typically with follow-up patients, I have a particular interest with spinal muscular atrophy, so I will see some of the SMA new patients, but I don't work with, I don't see patients along with the physicians. Darlene has commented ALS patients, she will see independently for follow-up visits. I think that these MDA care center clinics are really ideally, are the ideal place for APPs to practice in kind of following these chronic diseases. Myasthenia gravis is a great one to kind of follow those folks. Here's a Florence physician assistant who works outpatient and sees neuromuscular as well as epilepsy patients. I do physical exams on a regular basis for neuromuscular patients, such as patients with MG, et cetera. We'll wait just a few more minutes for other comments. So in regards to some of the other functional type testing or measurable testing, if you have a physical therapist who works with your group and you need, I did mention this in my talk, and you need to maybe assess response to a therapy, you can oftentimes have those physical therapists incorporate some of their testing. Hand-held dynamometry is a great way to detect resistance in the weakest of muscles, the slightest bit of resistance to the device. For those that are ambulatory, as I said, a six-minute walk test or a time to up and go are pretty useful. And again, it's nice to have the same examiner across the board, if that's at all possible. Any other questions or comments? I'm also involved in, another comment, I'm also involved in research for some of the investigational fr-tigamod patients. Sorry, Dr. Wolfe, I butchered that, with CIDP and my role is to perform the strength exams with those patients. Oh, that's great. Yeah, okay. Great. Well, I hope this was a useful webinar for you today, and thanks again so much for joining. Please feel free to provide any feedback in terms of what was useful, what wasn't, and what you might like to see in any future webinars. Well, Erin, I think if that is, if we have no other comments. Connie, thank you so much. This was wonderful. That was a great talk. Thank you. Yes. It's like Dr. Wolfe still has. That's right on the FGAR study. I would hope you all like seeing neuromuscular patients. Of course, they're my preference in neurology. Yeah, ditto. Well, thank you so much, Connie. We'll let everybody get back to the lunch break, and we'll see you all next week for week three of the webinar. Thank you again.

Neuromuscular Exam

Motor Examination

Upper Motor Neuron Systems

Lower Motor Neuron Systems

Hyperreflexia

Spasticity

Muscle Atrophy