• The bare minimum: Look for muscle atrophy and check extremity tone. Assess upper limb strength by checking for pronator drift and strength of wrist or finger extensors. Test for lower limb strength by asking pt to walk normally and on heels and toes and testing power of the toe extensors.

Power should be systematically tested for major movements at each joint (Table 180-1). Strength should be recorded using a reproducible scale (e.g., 0 = no movement, 1 = flicker or trace of contraction with no associated movement at a joint, 2 = movement present but cannot be sustained against gravity, 3 = movement against gravity but not against applied resistance, 4 = movement against some degree of resistance, and 5 = full power; 4 values can be supplemented with + and - signs to provide additional gradations). Speed of movement, ability to relax contractions promptly, and fatigue with repetition should all be noted. Loss in bulk and size of muscle (atrophy) should be noted, as well as the presence of irregular involuntary contraction (twitching) of groups of muscle fibers (fasciculations). Any involuntary movements should be noted at rest, during maintained posture, and with voluntary action.