ЇІИШШ

Medical Academy named after S.I. Georgievsky

of Vernadsky CFU

Department of Neurology and Neurosurgery

Lesson ^
Motor System.
Upper and Lower Motor Neurons. Pyramidal Tracts. Reflexes.
Aids to the examination of the voluntary movements.
Central and Peripheral Paralysis.
Motor Deficits due to Lesions at Specific Sites along the Motor Pathways.

Key points:
1. Types o f movements.
2. Anatomical basis o f voluntary movements.
3. Reflexes. Reflex arc. Normal and Pathological reflexes.
4. Corticospinal (Pyramidal) Tract and Corticonuclear (Corticobulbar) Tract.
5. Other Central Components o f the Motor System.
6. The technique o f examination o f the muscle strength, muscle tone, reflexes, pathological
reflexes, etc.
7. Paralysis Due to Upper Motor Neuron (UMN) Lesions - Central Paralysis. Symptoms o f
Central Paralysis and their pathogenesis.
8. Paralysis Due to Lower Motor Neuron (LMN) Lesions - Peripheral Paralysis. Symptoms o f
Peripheral Paralysis and their pathogenesis.

Questions for students:

Define the following terms:

Reflexes, voluntary movements, primary motor cortex, motor homunculus, upper motor neuron, lower motor
neuron, Betz cell, lateral corticospinal pathway, anterior corticospinal pathway, pyramidal tract, decussation
o f pyramids, corticonuclear pathway, anterior horn, anterior root, peripheral nerve, motor unit, central
paralysis, peripheral paralysis, paresis, plegia, monoparalysis, hemiparalysis, paraparalysis, tetraparalysis,
spasticity, flaccidity, muscle power, muscle tone, muscle bulk, deep tendon reflexes, superficial reflexes,
Babinski reflex, Oppenheim reflex, Gordon reflex, clonus, MRC scale, Jacksonian seizures, fasciculations,
muscular hypotrophy, muscular atrophy, hyporeflexia, hyperreflexia, motor nucleus, motor cranial nerve,
mixed cranial nerve, unilateral, bilateral, contralateral.

1. What are the steps involved in the motor exam?

2. Where are the cell bodies of the upper motor neurons (UMN) located?
3. Where are the cell bodies of the lower motor neurons (LMN) located?
4. What is the function of cortical upper motor neurons?
5. What do lower motor neurons (alpha motor neurons) do?
6. What is pyramidal pathway?
7. What is paralysis?
8. What are the major symptoms of central paralysis?
9. What are the major symptoms of peripheral paralysis?
10. How to distinguish central paralysis from peripheral one?
11. What is a reflex?
12. What is the function(s) of reflexes?
13. Which types of reflexes do exist?
14. How to exam motor system?
REFLEXES are subconscious stimulus-response mechanisms. The reflexes are extremely important in the
diagnosis and localization of neurologic lesions.

SIMPLE REFLEX ARC includes a receptor (eg, a special sense organ, cutaneous end-organ, or muscle spindle,
whose stimulation initiates an impulse); the afferent neuron, which transmits the impulse through a peripheral
nerve to the central nervous system, where the nerve synapses with lower motor neurons (LMN) or an
intercalated neuron; one or more interneurons, which for some reflexes relay the impulse to the efferent
neuron; the efferent neuron (usually an LMN), which passes outward in the nerve and delivers the impulse to
an effector; and an effector (eg, the muscle or gland that produces the response). Interruption of this simple
reflex arc at any point abolishes the response.

TYPES OF REFLEXES The reflexes of importance to the clinical neurologist may be divided into four groups:
superficial (skin and mucous membrane) reflexes, deep tendon (myotatic) reflexes, visceral (organic) reflexes,
and pathologic (abnormal) reflexes (Table 5-5). Reflexes can also be classified according to the level of their
central representation, for example, as spinal, bulbar (postural and righting reflexes), midbrain, or cerebellar
reflexes.

Reflexes Afferent Nerve Center Efferent Nerve

Superficial reflexes
Corneal Cranial V Pons Cranial VII
Nasal (sneeze) Cranial V Brain stem and upper cord Cranials V, VII, IX, X, and spinal nerves of
expiration
Pharyngeal and uvular Cranial IX Medulla Cranial X
Upper abdominal T 7 ,8, 9,10 T 7,8,9,10 T7, 8,9,10
Lower abdominal T10,11,12 T10,11,12 T10,11,12
Cremasteric Femoral LI Genitofemoral
Plantar Tibial SI, 2 Tibial
Anal Pudendal S4,5 Pudendal

Tendon reflexes
Jaw Cranial V Pons Cranial V
Biceps Musculocutaneous C5,6 Musculocutaneous
Triceps Radial C7,8 Radial
Brachioradialis Radial C5,6 Radial
Patellar Femoral L3,4 Femoral
Achilles Tibial S112 Tibial

Visceral reflexes
Light Cranial II Midbrain Cranial III
Accommodation Cranial II Occipital cortex Cranial III
Ciliospinal A sensory nerve T 1,2 Cervical sympathetics
Oculocardiac Cranial V Medulla Cranial X
Carotid sinus Cranial IX Medulla Cranial X
Bulbocavernosus Pudendal 52,3,4 Pelvic autonomic
Bladder and rectal Pudendal S2, 3,4 Pudendal and autonomies

Abnormal reflexes
Extensor plantar (Babinski) Plantar L3-5.S1 Extensor hallucis longus

THE MYOTATIC REFLEX (see the Table and Figure below) is a monosynaptic and ipsilateral muscle stretch
reflex (MSR). Like all reflexes, the myotatic reflex has an afferent and an efferent limb. Interruption of either
limb results in areflexia.

THE FIVE MOST COMMONLY TESTED MUSCLE STRETCH REFLEXES

Muscle Stretch Reflex Cord Segment Muscle
Ankle jerk S-1 - S-2 Gastrocnemius
Knee jerk L-2 - L-4 Quadriceps
Biceps jerk C-5 and C-6 Biceps
Forearm jerk C-5 and C-6 Brachioradialis
Triceps jerk C-7 and C-8 Triceps
 kneejerk reflex) ankle-jerk reflex)

C en tral C o m p o n e n ts o f th e M o to r S y ste m

CENTRAL PORTION of the motor system for voluntary movement consists of the primary motor cortex (area
4) and the adjacent cortical areas (particularly the premotor cortex, area 6), and the corticobulbar and
corticospinal tracts to which these cortical areas give rise (Figs. 3.1 and 3.2).

M o to r C ortical A re a s

PRIMARY MOTOR CORTEX (precentralgyrus, Fig. 3.1) is a band of cortical tissue that lies on the opposite
side of the central sulcus from the primary somatosensory cortex (in the postcentral gyrus) and, like it, extends
upward and past the superomedial edge of the hemisphere onto its medial surface.

MOTOR HOMUNCULUS. The area representing the throat and larynx lies at the inferior end of the primary
motor cortex; above it, in sequence, are the areas representing the face, upper limbs, trunk, and lower limbs
(Fig. 3.2).

MOTOR NEURONS are found not only in area 4 but also in the adjacent cortical areas. The fibers mediating
fine voluntary movements, however, originate mainly in the precentral gyrus. This is the site of the
characteristic, large pyramidal neurons (Betz cells), which lie in the fifth cellular layer of the cortex and send
their rapidly conducting, thickly myelinated axons into the pyramidal tract.

The motor neurons o f area 4 subserve fine, voluntary movement of the contralateral h a lf o f the body;
the pyramidal tract is, accordingly, crossed. Direct electrical stimulation of area 4, as during a neurosurgical
procedure, generally induces contraction of an individual muscle, while stimulation of area 6 induces more
complex and extensive movements, e.g., of an entire upper or lower limb.
 L a te ra l C o rtic o sp in al T ract (P y ra m id a l Tract)

A. FUNCTION . The lateral corticospinal tract mediates voluntary skilled motor activity, primarily of the
upper limbs. It is not fully myelinated until the end of the second year (Babinskis sign).
B. FIB E R CA LIBER. Approximately 90% of the fibers lie between 1 and 4 ц and 4% lie above 20 p,m
(from the giant cells of Betz).
C. O R IG IN AND TER M IN A TIO N
1. O rigin. The lateral corticospinal tract arises from layer V of the cerebral cortex from three cortical areas
in equal aliquots:
a. The premotor cortex (Brodmann’s area 6).
b. The primary motor cortex, or precentral gyrus (Brodmann’s area 4).
Arm, face, and fo o t areas. The arm and face areas of the motor homunculus arise from the lateral
convexity; the foot region of the motor homunculus is found in the paracentral lobule (see Figure 3.2).
c. The primary sensory cortex, or postcentral gyrus (Brodmann’s areas 3, 1, and 2).
2. Term ination. The lateral corticospinal tract terminates contralaterally, through interneurons, on ventral
horn motor neurons.
D. COURSE of the lateral corticospinal tract
1. Telencephalon. The lateral corticospinal tract runs in the posterior limb of the internal capsule in the
telencephalon.
2. M idbrain. The lateral corticospinal tract runs in the middle three-fifths of the crus cerebri in the
midbrain.
3. Pons. The lateral corticospinal tract runs in the base of the pons.
4. M edulla. The lateral corticospinal tract runs in the medullar)' pyramids. Between 85% and 90% of the
corticospinal fibers cross in the pyramidal decussation as the lateral corticospinal tract. The remaining 10% to
15% of the fibers continue as the anterior corticospinal tract.
5. Spinal cord. The lateral corticospinal tract runs in the dorsal quadrant of the lateral funiculus.
E. TRA N SECTIO N O F TH E LA TER A L C O R TIC O SPIN A L TRA CT
1. Above the m otor decussation, transection results in contralateral spastic paralysis.
2. In the spinal cord, transection results in ipsilateral spastic paralysis.

About 90% of all pyramidal tract fibers end in synapses onto interneurons, which then transmit the motor
impulses onward to the large а-motor neurons of the anterior horn, as well as to the smaller у-motor neurons
(Fig. 3.4).

C o rtic o n u c le a r (C o rtico b u lb ar) T ract

CORTICONUCLEAR FIBERS project bilaterally to all motor cranial nerve nuclei EXCEPT the lower part of
the motor facial nucleus and hypoglossal nucleus. The division of the facial nerve nucleus that innervates the
upper face (the orbicularis oculi muscle and above) receives bilateral corticonuclear input. The division of the
facial nerve nucleus that innervates the lower face receives only contralateral corticonuclear input. Hypoglossal
nucleus also receives only contralateral corticonuclear input.
 P e rip h e ra l C o m p o n e n ts o f th e M o to r S y s te m

PERIPHERAL PORTION OF THE MOTOR SYSTEM comprises the motor cranial nerve nuclei of the
brainstem, the motor anterior horn cells of the spinal cord, the anterior roots, the cervical and lumbosacral
nerve plexuses, the peripheral nerves, and the motor end plates in skeletal muscle.

ANTERIOR HORN CELLS (a and у motor neurons). The fibers not only of the pyramidal tract but also
of the non-pyramidal descending pathways as well as afferent fibers from the posterior roots, terminate on the
cell bodies or dendrites of the larger and smaller a motor neurons. Fibers of all of these types also make synaptic
contact with the small у motor neurons, partly directly, and partly through intervening interneurons and the
association and commissural neurons of the intrinsic neuronal apparatus of the spinal cord (Fig. 3.6). Some of
these synapses are excitatory, others inhibitory. The thin, unmyelinated neurites of the у motor neurons
innervate the intrafusal muscle fibers. In contrast to the pseudounipolar neurons of the spinal ganglia, the
anterior horn cells are multipolar. Their dendrites receive synaptic contact from a wide variety of afferent and
efferent systems (Fig. 3.6).

ANTERIOR ROOTS. The neurites of the motor neurons exit the anterior aspect of the spinal cord as
rootlets (fila radicularia) and join together, forming the anterior roots. Each anterior root joins the
corresponding posterior root just distal to the dorsal root ganglion to form a spinal nerve, which then exits the
spinal canal through the intervertebral foramen.

PERIPHERAL NERVE AND MOTOR END PLATE. There is one pair of spinal nerves for each segment
of the body. The spinal nerves contain afferent somatosensory fibers, efferent somatic motor fibers, efferent
autonomic fibers from the lateral horns of the spinal gray matter, and afferent autonomic fibers. At cervical
and lumbosacral levels, the spinal nerves join to form the nerve plexuses, which, in turn, give rise to the
peripheral nerves that innervate the musculature of the neck and limbs.

MOTOR UNIT. An anterior horn cell, its neurites, and the muscle fibers it innervates are collectively
termed a motor unit. Muscles participating in finely differentiated movements are supplied by a large number
of anterior horn cells, each of which innervates only a few (5 -20) muscle fibers; such muscles are thus
composed of small motor units. In contrast, large muscles that contract in relatively undifferentiated fashion,
such as the gluteal muscles, are supplied by relatively few anterior horn cells, each of which innervates 100­
500 muscle fibers (large motor units).
 Lesions o f C en tral M o to r P a th w a y s

SYNDROME OF CENTRAL (SPASTIC) PARALYSIS. This syndrome consists of:

- Diminished muscular strength and impaired fine motor control
- Spastic increased muscle tone
- Abnormally brisk deep tendon reflexes, possibly with clonus
- Hypoactivity or absence of exteroceptive reflexes (abdominal, plantar, and cremasteric reflexes)
- Pathological reflexes (Babinski, Oppenheim, Gordon reflexes)
- Preserved muscle bulk

L ocalizatio n o f L esions in th e C e n tra l M o to r S y s te m

LESION INVOLVING MOTOR CORTEX

(a in Fig. 3.7), such as a tumor, an infarct, or a
traumatic injury, causes weakness of part of the
body on the opposite side (contralateral
monoparesis). Monoparesis is seen in the face
or hand more frequently than elsewhere,
because these parts of the body have a large
cortical representation. An irritative lesion at
site (a) can cause focal (Jacksonian) seizures.

LESION INVOLVING INTERNAL CAPSULE

(b in Fig. 3.7) e.g. by hemorrhage or ischemia
causes contralateral spastic hemiplegia. The
corticonuclear tract is involved as well, so that
a contralateral facial palsy results, accompanied
by a central hypoglossal nerve palsy and central
facial nerve palsy. No other cranial nerve
deficits are seen, however, because the
remaining motor cranial nerve nuclei are
bilaterally innervated.

LESIONS AT THE LEVEL OF CEREBRAL

PEDUNCLE (c in Fig. 3.7), such as a vascular
process, a hemorrhage, or a tumor, produce
contralateral spastic hemiparesis, possibly
accompanied by an ipsilateral oculomotor nerve
palsy (Weber syndrome).

PONTINE LESIONS involving the pyramidal

tract (d in Fig. 3.7; e.g., a tumor, brainstem
ischemia, a hemorrhage) cause contralateral
hemiparesis possibly accompanying ipsilateral
trigeminal nerve deficit or abducens palsy.

LESIONS OF THE PYRAMIDAL TRACT IN

THE SPINAL CORD. A lesion affecting the
pyramidal tract at a cervical level (/"Fig. 3.7;
e.g., a tumor, myelitis, trauma) causes ipsilateral
spastic hemiplegia: ipsilateral because the tract
has already crossed at a higher level, and spastic
because it contains nonpyramidal as well as
pyramidal fibers at this level. A bilateral lesion
in the upper cervical spinal cord can cause
quadriparesis or quadriplegia. A lesion affecting
 the pyramidal tract in the thoracic spinal cord
(g in Fig. 3.7; e.g., trauma, myelitis) causes
spastic ipsilateral monoplegia of the lower limb.
Bilateral involvement causes paraplegia.___________________________________________________________

Clinical S y n d ro m e s o f M o to r U nit Lesions

SYNDROME OF PERIPHERAL (FLACCID) PARALYSIS. This syndrome consists of:

The syndrome o f flaccid paralysis consists o f the follow ing :
- Diminution of raw strength
- Hypotonia or atonia of the musculature
- Hyporeflexia or areflexia
- Muscle atrophy
- Fasciculation

The lesion can usually be localized more specifically to the anterior horn, the anterior root(s), the nerve
plexus, or the peripheral nerve with the aid of electromyography and electroneurography (nerve conduction
studies). If paralysis in a limb or limbs is accompanied by somatosensory and autonomic deficits, then the
lesion is presumably distal to the nerve roots and is thus located either in the nerve plexus or in the peripheral
nerve.

COMPONENTS OF MOTOR EXAMINATION:

1. Abnormal involuntary movements

2. Posture
3. M uscle bulk
4. M uscle tone
5. Power
6. Reflexes

A b n o rm a l in v o lu n ta ry m o v e m e n ts, p o s tu re a n d b u lk
Examination Technique:
a) patient should be sufficiently undressed but draped to preserve modesty
b) compare left to right and proximal to distal
c) observe for asymmetry, atrophy or hypertrophy
d) observe for abnormal involuntary movements

M uscle to n e
Examination Technique:
a) ensure the patient is relaxed
b) for assessment in the upper extremities, the patient may be lying or sitting. In the lower extremities,
tone is best assessed with the patient lying down
c) explain the examination technique to the patient before proceeding
d) spasticity (clasp knife) is velocity dependent and should be assessed by a quick flexion/extension of
the knee or the elbow or quick supination/pronation of the arm
e) rigidity (lead pipe) is continuous and not velocity dependent and the movement should be performed
slowly
f) "activated" rigidity; minor degrees of rigidity may be enhanced by having the patient activate the
opposite limb
g) rigidity in the neck can be assessed by slow flexion, extension and rotation movements

Normal Response:
a) normally minimal, if any resistance to passive movement is encountered
 Abnormal Response:
1.1. spasticity is a feature of an upper motor neuron lesion and maybe minor such as a spastic
catch or a very stiff limb that cannot be moved passively. Accompanying features may include
spasms, clonus, increased deep tendon reflexes and an extensor plantar response
1.2. rigidity is a continuous resistance to passive movement and is seen in extrapyramidal
disorders such as Parkinson’s disease
1.3. rigidity may be continuous or ratchety (cogwheeling). Cogwheeling is typically seen at the
wrists
1.4. hypotonia (flaccidity) or decreased tone is more difficult to appreciate but is seen with lower
motor neuron or cerebellar lesions

Pow er
Examination Technique:
a) power or strength is tested by comparing the patient’s strength against your own
b) start proximally and move distally
c) compare one side to the other
d) grade strength using the Medical Research Council (MRC) scale
e) where possible, palpate the muscle as the patient activates it
f) strength in the lower extremities is best assessed with the patient supine

Grade strength using the M edical Research Council (MRC) scale

MRC S cale

G rade Description

0 no contraction

1 flicker or trace of contraction

2 active movement with gravity eliminated

3 active movement against gravity

4* active movement against gravity and resistance

5 normal power
* grades 4 -, 4 and 4+ maybe used to indicate movement against slight, moderate and strong resistance
respectively

D e ep te n d o n re fle x e s
Examination Technique:
a) the patient should be relaxed
b) explain to the patient the examination technique
c) use a neurological hammer for examination
d) before concluding that reflexes are absent, have the patient re-enforce by performing an isometric
contraction of other muscles (e.g. clench teeth or opposite limb for upper extremity reflexes or pull
hooked fingers apart for lower extremity reflexes)
e) before concluding that ankle reflexes are absent, position the patient in a chair by having them kneel
where one would normally sit, squeeze the back of the chair for reinforcement, on your count of three,
just as you deliver the strike to the Achilles’ tendon which should be gently stretched by passive
dorsiflexion of the ankle

Deep tendon reflexes tested:

a) Upper extremities: biceps (C5, C6), brachioradialis (C5, C6), triceps (C6, C7), finger flexors (C6-T1)
b) Lower extremities: knee or patellar (L2, 3, 4), ankle (S1, S2)
 G rade D escription

0 absent

1+ hypoactive

2+ normal

3+ hyperactive without clonus

4+ hyperactive with clonus

C lonus
If reflexes are hyperactive, test for ankle clonus.
Examination Technique:
a) ask the patient to relax
b) support the knee in a partly flexed position
c) quickly dorsiflex the foot and observe for rhythmic clonic movements

A b d o m in a l R e fle x e s
Examination Technique:
a) explain the examination technique
b) the patient should be lying down and relaxed with their arms by their side
c) a blunt object such as a key or tongue blade may be used (A safety pin may also be used as long as
the stimulus is delivered lightly)
d) stroke the abdomen lightly on each side in an inward direction above and below the umbilicus
e) note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus

Abdominal reflexes tested:

o above umbilicus (T8, T9, T10) and below umbilicus (T10, T11, T12).

Normal Response:
a) Some studies indicate that up to 10% of people with no nervous system disease may have absence of
one or more of the deep tendon reflexes. In general however, deep tendon reflexes are rarely absent in
normal persons if the technique of eliciting them is adequate. Note that the reflex response depends
on the force of the stimulus. Reflexes should be symmetrical
b) some individuals especially young anxious people may have brisk reflexes which are not necessarily
pathological. There should be no asymmetry
c) usually clonus is abnormal although a few beats of non-sustained transient clonus may occasionally
be seen
d) abdominal reflexes are usually obtainable in healthy non-obese individuals. They may be absent in
obese individuals or those with lax abdominal musculature. Local diminishment or absence, suggests
a disturbance in the continuity of the reflex arc (afferent nerve, motor center, efferent nerve). Loss,
when associated with exaggeration of deep tendon reflexes implies a pyramidal tract lesion
 B ab in sk i r e s p o n s e
Examination Technique:
a) explain the examination technique to the patient and ask them to relax.
b) stroke the lateral aspect of the sole of each foot and then come across the ball of the foot medially with
a sharp object.

O p p e n h e im re fle x
Examination Technique:
a) explain the examination technique to the patient and ask them to relax.
b) stroke downward with the examiner’s thumb on the patient’s shin

G o rd o n re fle x
Examination Technique:
a) explain the examination technique to the patient and ask them to relax.
b) squeeze the patient’s calf muscles
 QUESTIONS FOR SELF-EDUCATION

1. Which of the following are true about DEEP REFLEXES (choose applicable):
1. They are also called muscle stretch reflexes
2. They are also called myotatic reflexes
3. They are also called reflexes from the skin
4. They are also called pathological reflexes
5. Spinal reflexes are mediated at spinal level
6. They include Babinski and Gordon reflexes
7. Accessed by tapping the muscle tendon with reflex hammer and observing response
8. Accessed by squeezing the patient’s calf muscles and observing response
9. They include Biceps and Triceps reflexes
10. They include all abdominal reflexes
11. They can be changed only due to lesions of upper motor neurons (UMN)
12. They can be changed only due to lesions of lower motor neurons (LMN)
13. They can be changed due to lesions of both motor neurons - UMN and LMN
14. They have both afferent and efferent components
15. They have neither afferent nor efferent components

2. Which of the following are true about SUPERFICIAL REFLEXES (choose applicable):
1. They are also called muscle stretch reflexes
2. They are also called myotatic reflexes
3. They are also called reflexes from the skin
4. They are also called pathological reflexes
5. Accessed by stroking of the abdomen around the umbilicus and observing response
6. They include Babinski and Gordon reflexes
7. Accessed by tapping the muscle tendon with reflex hammer and observing response
8. Accessed by squeezing the patient’s calf muscles and observing response
9. They include Biceps and Triceps reflexes
10. They include all abdominal reflexes
11. They can be changed only due to lesions of upper motor neurons (UMN)
12. They can be changed only due to lesions of lower motor neurons (LMN)
13. They can be changed due to lesions of both motor neurons - UMN and LMN
14. They have both afferent and efferent components
15. They have neither afferent nor efferent components

3. Which of the following are true about SIMPLE REFLEX ARC (choose applicable):
1. It includes an effector
2. It includes an interneuron
3. It includes fibers of spinothalamic pathway
4. It includes neurons located in the grey matter of the spinal cord
5. It includes an efferent neuron
6. It can be monosynaptic
7. It can be polysynaptic

4. Indicate all types of reflexes (choose applicable):

1. Deep tendon reflexes
2. Pathological reflexes
3. Undifferentiated reflexes
4. Abnormal reflexes
5. Reflexes from mucosae
6. Myotatic reflexes
7. Wasted reflexes
8. Visceral reflexes
9. Floating reflexes
5. Which of the following are true about BABINSKI REFLEX (choose applicable):
1. Babinski reflex is a normal plantar response in adults
2. Babinski reflex is a normal plantar response in newborns
3. Babinski reflex is also called reflex from the skin
4. Babinski reflex is tonic dorsiflexion of the great toe on stimulation of the lateral sole of the foot
5. Babinski reflex is accessed by stroking of the abdomen around the umbilicus
6. Babinski reflex is accessed by tapping the muscle tendon with reflex hammer
7. Babinski reflex is accessed by squeezing the patient’s calf muscles
8. Babinski reflex is curving of the great toe down and inwards on stimulation of the lateral sole of
the foot
9. Babinski reflex indicates lesion of the lower motor neuron (LMN)
10. Babinski reflex indicates lesion of the upper motor neuron (UMN)
11. Babinski reflex indicates lesion of the pyramidal pathway

6. The MOTOR SYSTEM is responsible for the control of the following (choose applicable):
1. Proprioception
2. Timing of voluntary movements
3. Position sense
4. Direction of voluntary movements
5. Amplitude of voluntary movements
6. Deep sensation (including vibration sense)
7. Coordination of voluntary movements
8. Frequency of involuntary movements
9. Amplitude of involuntary movements

7. What is true about the UPPER MOTOR NEURON (choose applicable):

1. Itis located in the postcentral gyrus
2. Itis located in the thalamus (VPL and VPM nuclei)
3. Itis located in the cerebral cortex
4. Itis located in the anterior horns of the spinal cord
5. Itis located in the precentral gyrus
6. It is a place of origin of the pyramidal tract
7. It is a place of origin of the fasciculus cuneatus and gracilis
8. It’s impairment is resulted in peripheral paralysis
9. It’s impairment is resulted in central paralysis

8. What is true about the LOWER MOTOR NEURON (choose applicable):

1. Itis located in the precentral gyrus
2. Itis located in the dorsal spinal ganglia
3. It is located in the cerebral cortex
4. It is located in the anterior horns of the spinal cord
5. It is located in the anterior roots
6. It is located in the posterior horns of the spinal cord
7. It is a place of origin of the pyramidal tract
8. It’s impairment is resulted in peripheral paralysis
9. It’s impairment is resulted in central paralysis

9. Indicate functions of deep tendon reflexes (choose applicable):

1. Adjust for unexpected changes in posture or position
2. Transmit sensory information (deep sensation) to the thalamus
3. Organize movement patterns - reciprocal inhibition and autogenic facilitation
4. Organize information flow from muscles to the cortex
5. Allow for rapid protection from painful or damaging stimulation
10. Reflex arcs below are correct EXCEPT (choose applicable):
1. Biceps reflex: C6 - C7
2. Triceps reflex: C7 - C8
3. Biceps reflex: C5 - C6
4. Knee reflex: L4 - L5
5. Triceps reflex: C5 - C7
6. Brachioradialis reflex: C5 - C6
7. Ankle reflex: S1 - S2
8. Knee reflex: L3 - L4
9. Ankle reflex: S3
10. Brachioradialis reflex: C7 - C8

11. Indicate motor nerve cells which send their axons to skeletal muscles (choose applicable):
1. Interneurons in the spinal cord
2. Lower motor neurons
3. Pseudounipolar neurons
4. Receptors in muscles
5. Betz cells
6. Alpha motorneurons
7. Upper motor neurons
8. Purkinje cells
9. Central motor neurons
10. Peripheral motor neurons

12. Indicate motor nerve cells which send their axons to the different types of motor nuclei in the brainstem
and gray matter of the spinal cord (choose applicable):
1. Interneurons in the spinal cord
2. Lower motor neurons
3. Pseudounipolar neurons
4. Receptors in muscles
5. Betz cells
6. Alpha motorneurons
7. Upper motor neurons
8. Purkinje cells
9. Central motor neurons
10. Peripheral motor neurons

13. Corticospinal pathway travels through the following structures (choose applicable):
1. Betz cells
2. Corona radiata
3. Upper motor neurons
4. Thalamus (VPM and VPL)
5. Posterior limb of the internal capsule
6. Posterior horns of the spinal cord
7. Vermis of the cerebellum
8. Anterior limb of the internal capsule
9. Base of the medulla oblongata
10. Spinal cord
14. Corticospinal pathway decussates at the level of (choose applicable):
1. Upper part of the spinal cord
2. Cervical level of the spinal cord
3. C2 - C3 spinal segments
4. Anterior horns of the spinal cord
5. Caudal part of the medulla oblongata
6. Thalamus
7. Anterior grey commissure of the spinal cord
8. Base of the pons
9. Anterior white commissure of the spinal cord
10. It does not decussate and descend ipsilaterally

15. Indicate motor nuclei of cranial motor and mixed nerves which receive motor information from both (left
and right) cerebral motor areas (choose applicable):
1. Optic nerve nuclei
2. Oculomotor nerve motor nucleus
3. Upper part of the facial nucleus
4. Motor nucleus of the trigeminal nerve
5. Motor nucleus of the vagus nerve
6. Lower part of the facial nucleus
7. Hypoglossal nerve nucleus
8. Motor nucleus of the glossopharyngeal nerve
9. Abducens nerve nucleus
10. Trochlear nerve nucleus

16. Slight paralysis or weakness affecting one side of the body (choose applicable):
1. Hemiplegia
2. Total paralysis
3. Paraplegia
4. Hemiparesis
5. Quadriparalysis
6. Ataxia
7. Monoparesis
8. Tetraparesis
9. Monoplegia
10. Paraparesis

17. Paralysis of both legs and the lower part of the body (choose applicable):
1. Hemiplegia
2. Total paralysis
3. Paraplegia
4. Hemiparesis
5. Quadriparalysis
6. Ataxia
7. Monoparesis
8. Tetraparesis
9. Monoplegia
10. Paraparesis
18. Severe paralysis affecting only one side of the body (choose applicable):
1. Hemiplegia
2. Total paralysis
3. Paraplegia
4. Hemiparesis
5. Quadriparalysis
6. Ataxia
7. Monoparesis
8. Tetraparesis
9. Monoplegia
10. Paraparesis

19. Severe paralysis of all four extremities (choose applicable):

1. Hemiplegia
2. Total paralysis
3. Paraplegia
4. Hemiparesis
5. Quadriparalysis
6. Ataxia
7. Monoparesis
8. Tetraparesis
9. Monoplegia
10. Paraparesis

20. Slight paralysis or weakness affecting only one arm or one leg (choose applicable):
1. Hemiplegia
2. Total paralysis
3. Paraplegia
4. Hemiparesis
5. Quadriparalysis
6. Ataxia
7. Monoparesis
8. Tetraparesis
9. Monoplegia
10. Paraparesis

21. What does a lower motorneurone lesion produce (choose applicable):

1. Hemiplegia or hemiparesis
2. Peripheral paralysis of innervated muscles
3. Increased deep tendon reflexes with clonuses
4. Ataxia of stance and gait
5. Muscle atrophy
6. Positive Babinski reflex
7. Fasciculations in muscles
8. Decreased or absent deep tendon reflexes
9. Increased muscle tone
10. Decreased muscle strength
11. Decreased muscle tone
12. Absence of muscle atrophy
22. What does an upper motorneurone lesion produce (choose applicable):
1. Muscle atrophy
2. Increased deep tendon reflexes with clonuses
3. Ataxia of stance and gait
4. Decreased muscle tone
5. Positive Babinski reflex
6. Fasciculations in muscles
7. Absence of muscle atrophy
8. Decreased or absent deep tendon reflexes
9. Increased muscle tone
10. Decreased muscle strength
11. Peripheral paralysis of innervated muscles

23. Why are reflexes important? (choose applicable):

1. Control of posture
2. Control of involuntary movements
3. Control of locomotion
4. Control of equilibrium
5. Automatic and regulatory functions

24. Where are lower motorneurons located? (choose applicable):

1. Premotor area of the brain
2. Motor area of the brain
3. Corona radiata
4. Motor nuclei of the cranial nerves
5. Thalamus (VPM and VPL)
6. Posterior horns of the spinal cord
7. Anterior limb of the internal capsule
8. Base of the medulla oblongata
9. Anterior horns of the spinal cord

25. Where are upper motorneurons located? (choose applicable):

1. Motor area of the brain
2. Corona radiata
3. Precentral gyrus
4. Motor nuclei of the cranial nerves
5. Postcentral gyrus
6. Posterior horns of the spinal cord
7. Anterior limb of the internal capsule
8. Base of the medulla oblongata
9. Anterior horns of the spinal cord
26. Using the figure on the left side of the table
indicate all possible motor findings due to
LESION A (choose applicable):
1. Peripheral contralateral paralysis
2. Decreased muscle strength
3. Increased muscle strength
4. Central contralateral hemiparalysis
5. Increased muscle tone
6. Decreased deep tendon reflexes
7. Positive Babinski reflex
8. Central contralateral monoparalysis
9. Peripheral ipsilateral paralysis
10. Fasciculations
11. Central ipsilateral hemiparalysis
12. Increased deep tendon reflexes
13. Decreased muscle tone
14. Clonuses
______ 15. Decreased superficial reflexes______
27. Using the figure on the left side of the table
indicate all possible motor findings due to
LESION B (choose applicable):
1. Peripheral contralateral paralysis
2. Decreased muscle strength
3. Increased muscle strength
4. Central contralateral hemiparalysis
5. Increased muscle tone
6. Decreased deep tendon reflexes
7. Positive Babinski reflex
8. Central contralateral monoparalysis
9. Peripheral ipsilateral paralysis
10. Fasciculations
11. Central ipsilateral hemiparalysis
12. Increased deep tendon reflexes
13. Decreased muscle tone
14. Clonuses
______ 15. Decreased superficial reflexes______
28. Using the figure on the left side of the table
indicate all possible motor findings due to
LESION C (choose applicable):
1. Peripheral contralateral paralysis
2. Decreased muscle strength
3. Increased muscle strength
4. Central contralateral hemiparalysis
5. Increased muscle tone
6. Decreased deep tendon reflexes
7. Positive Babinski reflex
8. Central contralateral monoparalysis
9. Peripheral ipsilateral paralysis
10. Fasciculations
11. Central ipsilateral hemiparalysis
12. Increased deep tendon reflexes
13. Decreased muscle tone
14. Clonuses
15. Decreased superficial reflexes______
29. Using the figure on the left side of the table
indicate all possible motor findings due to
LESION D (choose applicable):
1. Peripheral contralateral paralysis
2. Decreased muscle strength
3. Increased muscle strength
4. Central contralateral hemiparalysis
5. Increased muscle tone
6. Decreased deep tendon reflexes
7. Positive Babinski reflex
8. Central contralateral monoparalysis
9. Peripheral ipsilateral paralysis
10. Fasciculations
11. Central ipsilateral hemiparalysis
12. Increased deep tendon reflexes
13. Decreased muscle tone
14. Clonuses
15. Decreased superficial reflexes

30. Using the figure on the left side of the table

indicate all possible motor findings due to
LESION E (choose applicable):
1. Peripheral contralateral paralysis
2. Decreased muscle strength
3. Increased muscle strength
4. Central contralateral hemiparalysis
5. Increased muscle tone
6. Decreased deep tendon reflexes
7. Positive Babinski reflex
8. Central contralateral monoparalysis
9. Peripheral ipsilateral paralysis
10. Fasciculations
11. Central ipsilateral hemiparalysis
12. Increased deep tendon reflexes
13. Decreased muscle tone
14. Clonuses
______ 15. Decreased superficial reflexes______