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Examination of the
Motor System
In association with
Dr David Smith
Consultant Neurologist
Walton Centre for Neurology
and ...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Note
 This study guide is designed with
right-h...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
The motor system
Messages travel from the motor ...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Tone
 NORMAL
 passive movement of the limbs sh...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Pyramidal tract (UMN) lesion;
SPASTICITY
 There...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Patterns of weakness 1
 Help to localise the pr...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Motor power
 Ask the patient to make the requir...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Finger flexion
 Ask patient to curl fingers
tow...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Knee flexion (L5/S1)
Position patient seated wit...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Knee extension (L3/4)
Position patient seated
wi...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Patterns of weakness 2
 UMN lesion
 there is w...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Documenting reflexes
Absent -
Present with reinf...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Testing for reflexes
 Position the limb correct...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, Uni...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Patterns of reflex change
 UMN lesion
 Reflexe...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Summary
Parameter UMN lesion LMN lesion (periphe...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Reminder
 What you have learned so far will all...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Finger abduction
Support patient’s wrist with yo...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Thumb abduction (T1, median)
Support patient’s w...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Thumb opposition (T1,Median)
Support patient’s w...
10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
Thumb adduction (T1, Ulnar)
Support patient’s wr...
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Muscle Power and Tone Examination

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Muscle Power and Tone Examination

  1. 1. Examination of the Motor System In association with Dr David Smith Consultant Neurologist Walton Centre for Neurology and Neurosurgery 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 110/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK
  2. 2. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Note  This study guide is designed with right-handed examiners in mind.  please substitute appropriately if left- handed  Arrows on photographs depict the direction of movement of the limb
  3. 3. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 3 CONTENTS  Tone and Clonus  Limb Power  Reflexes
  4. 4. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK The motor system Messages travel from the motor cortex via subcortical nuclei and brainstem to spinal cord, thence to nerve roots, peripheral nerves and finally to muscles  Upper Motor Neurone (UMN)  From the motor cortex to anterior horn cell of the spinal cord  Lower Motor Neurone (LMN)  from anterior horn cell to neuromuscular junction
  5. 5. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 5 Testing muscle tone and clonus
  6. 6. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Tone  NORMAL  passive movement of the limbs should be neither floppy nor stiff  INCREASED due to -  lesions of pyramidal tract (UMN) – SPASTICITY  or lesions of the extrapyramidal tract – RIGIDITY  REDUCED  caused by LMN lesions, is called FLACCIDITY Abnormal tone will be accompanied by other signs which help to localise the lesion 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 6
  7. 7. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 7 Testing for spasticity in the arms 1  Support the elbow with your left hand  Hold patient’s hand as if shaking hands  Rapidly supinate and pronate the arm  Use the same technique on each arm  Always use the same hand to assess movement for the patients right and left
  8. 8. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 8 Testing for spasticity in the arms 2  While still supporting the elbow passively flex and extend the elbow  Use same technique on both arms  If tone is normal there will be no resistance to these movements
  9. 9. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 9 Testing for spasticity in the legs 1  With the patient relaxed, place your hands on the thigh and roll the whole leg  Observe the movement of the foot  If tone is normal the range of movement of the foot is similar to the rotation of the leg Alternatively  Flex and extend the knee  If tone is normal there should be no resistance to this movement
  10. 10. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 10 Lower Limb Tone 2
  11. 11. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 11 Testing for spasticity in the legs 2 (Clonus) Position the patient with the knee flexed and the hip externally rotated  Sharply dorsiflex the foot In most people with normal tone the foot will not move  But 2-3 beats of clonus (plantar flexion followed by dorsiflexion of the foot) can be within normal limits Sustained clonus is a sign of an upper motor neurone problem
  12. 12. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Pyramidal tract (UMN) lesion; SPASTICITY  There is initial resistance to movement which gives way as the movement continues  Arm; SUPINATOR CATCH  Leg; CLASP KNIFE phenomenon  There is usually SUSTAINED CLONUS (>3-4 beats) 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 12
  13. 13. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 13 Testing Power
  14. 14. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 14 The grading of muscle power (MRC) Grade Meaning 0 Complete paralysis 1 Flicker of contraction possible 2 Movement possible if gravity eliminated 3 Movement against gravity but not resistance 4 Movement possible against some resistance 5 Power normal (it is not normally possible to overcome a normal adult’s power) 6
  15. 15. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Patterns of weakness 1  Help to localise the problem within the nervous system  A limited examination allows you to differentiate between UMN and LMN lesions  Different patterns of LMN weakness may require more detailed examination 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 15
  16. 16. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Motor power  Ask the patient to make the required movement  Attempt to overcome the movement remembering that this is not a test of relative strength  Avoid mechanical advantage to the examiner 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 16
  17. 17. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 17 Summary of motor supply to the upper limb Extension C7/8 Flexion C5/6 Extension C7/8 Flexion C6/7 Extension C7/8 Flexion C7/8 Abduction C5/6 Adduction C6/7/8 Adduction C8/T1
  18. 18. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 18 Shoulder abduction (C5/6) and adduction (C6/7/8) Position patient with shoulders abducted to 90°  Ask patient to maintain position whilst you attempt to overcome by pressing down on upper arm Position patient with arms at approx 30° of abduction, with elbows flexed  Ask patient to bring elbows towards side against resistance “Stop me pushing your arms down” “Stop me pushing your arms up”
  19. 19. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 19 Elbow flexion 2 (C5/6) and extension (C7/8) Position patient with elbow flexed  Ask them to resist your attempt to straighten arm Position patient with elbow extended beyond 90 °  Ask them to resist your attempt to flex the elbow (‘push me away’) “Pull me towards you” “Push me away”
  20. 20. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 20 Finger extension (C7, C8) Position patient with fingers extended  While supporting wrist ask them to resist your attempt to flex fingers “Stop me trying to bend your fingers down”
  21. 21. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Finger flexion  Ask patient to curl fingers towards palm  And to keep fingers flexed while you attempt to straighten them Alternatively  ask them to squeeze two of your fingers placed in either of the patient’s palms 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 21 “Stop me pulling your fingers straight” “Squeeze my fingers”
  22. 22. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 22 Summary of lower limb motor supply Abduction L4/5/S1 Adduction L2/3/4 Inversion L5/S1 Eversion L5/S1 Extension L3/4 Flexion L2/3Extension L5/S1/2 Dorsiflexion L4 Plantar flexion S1/S2 Flexion L5/S1
  23. 23. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 23 Hip flexion (L2/3) and extension (L5/S1/2) Position the patient with the leg elevated to approx 30°  Attempt to overcome by pressing down on thigh Position patient with leg flat on couch  Place your hand underneath thigh and attempt to elevate leg while patient presses down “Stop me trying to raise your leg up” “Stop me pushing your leg down”
  24. 24. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Knee flexion (L5/S1) Position patient seated with knee flexed  Place your left hand on patient’s thigh  Place your right hand behind heel/ankle/calf  Ask patient to bring heel towards buttocks against resistance 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 24 “Stop me trying to straighten your leg”
  25. 25. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Knee extension (L3/4) Position patient seated with knee flexed  Place your left hand on patient’s thigh  Place your right hand over patient’s shin  Ask patient to straighten leg against resistance 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 25 “Stop me trying to bend your knee”
  26. 26. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 26 Dorsiflexion (L4) and plantar flexion (S1/2) of the foot  Dorsiflexion: Ask patient to bring foot upwards  Attempt to overcome by pressing down on foot  Plantar flexion: Ask patient to push foot down  Attempt to overcome by pressing upwards on sole “Stop me pushing your foot down” “Stop me pushing your foot up”
  27. 27. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Patterns of weakness 2  UMN lesion  there is weakness of the;  extensors in the arms  flexors in the legs  The unopposed action of unaffected muscles produces the characteristic posture seen in patients with stroke  LMN lesion  involvement of nerve endings (peripheral neuropathy) produces a predominantly distal pattern of weakness 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 27
  28. 28. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 28 Testing the reflexes
  29. 29. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 29 Reflexes Normal reflex arc requires :-  Stimulus to stretch receptors  Intact sensory afferent pathway  Link with a motor unit  Intact motor neurone  Contractile element The order in which you test reflexes should be logical and may vary from one examiner to another The patient must be relaxed
  30. 30. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Documenting reflexes Absent - Present with reinforcement +/- Normal + or ++ Brisk +++ 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 30 Reflexes can be recorded as follows:
  31. 31. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 31 The reflexes Biceps (C5/6) Triceps (C7/8) Supinator (C5/6) Finger (C8) Ankle (S1/2) Plantar (L5/S1/2) Knee (L3/4) Abdominal
  32. 32. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Testing for reflexes  Position the limb correctly  Hold the tendon hammer like a hammer  Place your finger over the tendon and strike it,  for some reflexes you will strike the tendon itself (see slides below)  (except the ankle – see slide 38)  Observe the relevant muscle for contraction  (not the limb movement)  Be aware of the range of normality.  Abnormal reflexes rarely seen without other relevant signs10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 32
  33. 33. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 33 Reinforcement Where a reflex appears difficult to elicit, reinforcement might be tried.  Ask the patient to close their eyes:  lower limb  ask the patient to grasp the fingers of each hand and to pull apart on instruction just as the reflex is tested  upper limb  the teeth may be clenched Reinforcement for a lower limb reflex – with patient’s eyes closed
  34. 34. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 34 The upper limb Reflex Testing
  35. 35. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 35 Supinator (brachioradialis) reflex (C5/6)  Position patient sitting relaxed, with elbows flexed and hands resting on thigh/groin  Place your left index/middle finger(s) over supinator tendon  Strike finger(s) with falling head of hammer  Observe slight elbow flexion or contraction of belly of brachioradialis  Observe for contraction of brachioradialis here  You may notice momentary elbow flexion
  36. 36. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 36 Biceps reflex (C5/6)  In same position clasp patient’s elbow so that biceps tendon can be felt under your thumb or finger  Strike your thumb or finger  Observe elbow flexion  there may be little movement  but you should feel the contraction
  37. 37. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 37 Triceps reflex (C7/8) Position patient with their arm across the abdomen with elbow flexed to 90°  Strike the triceps tendon direct  Observe  for elbow extension  or contraction of the muscle bellyYou may feel muscle contract with free hand
  38. 38. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 38 The finger jerk (C8) Ask patient to rest their fingers on index and middle fingers of your left hand and curl their fingers slightly  Strike your fingers  Patient’s fingers may flex  This can be normal
  39. 39. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 39 The lower limb Reflex Testing
  40. 40. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 40 Knee reflex (L3/4) Support one or both knees, so they are slightly bent  Strike the patellar tendon direct  Observe  quadriceps contraction  with or without knee extension Infrapatellar ligament Patella
  41. 41. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 41 Ankle reflex S1/2 Patient is seated Place your left hand on ball of patient's foot Passively dorsiflex the ankle  Strike your fingers  Observe/feel for plantarflexion
  42. 42. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 42 Plantar reflex (L5/S1/2) Patient seated with leg flat on couch  Drag thumbnail or blunt object along the lateral border of the foot and across the sole towards other side  The normal response is flexion of the big toe  may be absent if feet are cold
  43. 43. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Patterns of reflex change  UMN lesion  Reflexes brisk below the level of the lesion  plantar response is usually extensor  A pathologically brisk finger flexion jerk is the upper limb equivalent of an extensor plantar response  LMN lesion (peripheral neuropathy)  reflexes are absent  distal reflexes are first to be lost 10/13/2011 43
  44. 44. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Summary Parameter UMN lesion LMN lesion (peripheral neuropathy)* Posture Flexed UL, Extended LL May be wasting, fasciculation Tone Increased (spasticity) Reduced (flaccidity) Power Weakness of UL extensors and LL flexors Distal weakness Reflexes Brisk Absent Plantar response Extensor Flexor or absent 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 44 There are other patterns of lower motor neurone lesions (nerve root, individual peripheral nerve). *
  45. 45. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Reminder  What you have learned so far will allow you to distinguish between UMN and LMN lesions  In future you will learn additional skills needed to localise lesions according to particular presentations  E.g. examination of the intrinsic hand muscles in someone with weakness or tingling in the hand/fingers. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 45
  46. 46. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Finger abduction Support patient’s wrist with your left hand  Ask patient to spread fingers wide  Ask patient to maintain this position while you try to push little finger inwards  Ask patient to maintain this position while you try to push index finger inwards 10/13/2011 46 “Stop me pushing your fingers”
  47. 47. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Thumb abduction (T1, median) Support patient’s wrist with your left hand  Ask patient to lift thumb upwards  Ask them to maintain that position against resistance 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK 47 “Stop me pushing your thumb down to your palm” Thumb abduction is 90° to finger abduction
  48. 48. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Thumb opposition (T1,Median) Support patient’s wrist with left hand  Ask patient to place tip of thumb onto tip of index finger  And to hold this position while you try to separate the thumb and index finger 48 “Stop me pulling your fingers apart”
  49. 49. 10/13/2011 © Clinical Skills Resource Centre, University of Liverpool, UK Thumb adduction (T1, Ulnar) Support patient’s wrist with your left hand  Ask patient to trap your index and middle fingers between the base of their thumb and their index finger  Ask them to maintain that position while you try to lift their thumb 10/13/2011 49 “Stop me trying to lift your thumb up”

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