Exame Neurológico Motor

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AULA PRÁTICA | EXAME NEUROLÓGICO MOTOR
Reflexos e força muscular — roteiro ilustrado pelo Bates 1
Aula prática: reflexos osteotendinosos e força
muscular
Transcrição em texto corrido ampliada exclusivamente com o capítulo 24 de Bates: propedêutica
médica, 13. edição. Cada manobra traz técnica, resposta esperada e as raízes indicadas no livro.
Preparação, comparação e graduação
Explique cada manobra e peça ao paciente que relaxe o segmento examinado. Observe previamente a
postura, o volume muscular, o tônus e a presença de fasciculações. Na força, estabilize a articulação e
solicite que o paciente faça um movimento específico enquanto você aplica resistência no sentido
oposto. Compare sempre os dois lados, levando em conta dor, compreensão do comando e
dominância. Nos reflexos, sustente o membro e use golpes rápidos, com intensidade semelhante de
ambos os lados; observe a velocidade e a amplitude da resposta. Uma diferença consistente entre
direita e esquerda costuma ser mais informativa do que uma resposta simétrica discretamente viva ou
reduzida.
A força muscular é registrada de 0 a 5: 5 significa movimento contra resistência plena; 4, movimento
contra alguma resistência; 3, movimento contra a gravidade, sem resistência adicional; 2, movimento
após eliminar a gravidade; 1, contração observável ou palpável sem deslocamento; e 0, nenhuma
contração detectável. Se houver fraqueza, repita o teste sem resistência, depois sem gravidade e, por
fim, palpe o músculo. Para os reflexos, a escala do Bates vai de 0 a 4: 0 indica ausência; 1, resposta
discreta ou que exige reforço; 2, resposta média; 3, resposta mais viva, interpretada no contexto; e 4,
resposta muito viva acompanhada de clônus. Registre a graduação e o lado.
Um reflexo difícil de obter pode ser facilitado por uma contração isométrica distante do músculo
examinado. Para pesquisar os reflexos das pernas, o Bates descreve pedir que o paciente entrelace os
dedos e puxe uma mão contra a outra. A presença de hiperreflexia junto com espasticidade e outros
sinais de trato corticospinal, ou de hiporreflexia com atrofia e fasciculações, orienta a investigação;
isoladamente, a graduação de um reflexo não fecha um diagnóstico.
Reflexos osteotendinosos
1. Reflexo bicipital — C5 e C6
Com o paciente sentado ou deitado, sustente o braço e deixe
o cotovelo parcialmente flexionado. Coloque seu polegar ou
outro dedo firmemente sobre o tendão do bíceps, na face
anterior do cotovelo, e bata sobre o seu dedo com o
martelo, em direção ao tendão. Observe e palpe a contração
do bíceps, acompanhada de flexão do cotovelo. Repita do lado
oposto com apoio e golpe equivalentes.
Figura 24.47. Bicipital: dedo apoiado no tendão.
Fonte: Bates, 13. ed., cap. 24, figura 24.47.
AULA PRÁTICA | EXAME NEUROLÓGICO MOTOR
Reflexos e força muscular — roteiro ilustrado pelo Bates 2
2. Reflexo braquiorradial ou estilorradial — C5 e
C6
Deixe a mão do paciente repousar no abdome ou no colo, com
o antebraço em semipronação e relaxado. Percuta o rádio a
cerca de 5 a 10 cm acima do punho, próximo ao tendão do
braquiorradial. A resposta descrita no Bates é flexão do
cotovelo com supinação do antebraço. Se for sutil, observe o
movimento e palpe a contração, comparando os lados. A raiz
ausente na tabela anterior foi preenchida conforme o livro.
Figura 24.52. Braquiorradial: percussão acima
do punho.
Fonte: Bates, 13. ed., cap. 24, figura 24.52.
3. Reflexo tricipital — C6 e C7
Sustente o braço, flexione o cotovelo e deixe o antebraço
relaxado, com a palma voltada para o corpo. Percuta
diretamente o tendão do tríceps, na parte posterior do braço,
logo acima do cotovelo. Procure a contração do tríceps e a
extensão do antebraço. Se o paciente tiver dificuldade para
relaxar, apoie melhor o braço e solicite que o deixe solto
antes de repetir a percussão.
Figura 24.49. Tricipital: percussão do tendão
posterior.
Fonte: Bates, 13. ed., cap. 24, figura 24.49.
4. Reflexo patelar ou do quadríceps — L2, L3 e
L4
Com o paciente sentado e a perna solta, ou deitado com o
joelho flexionado e apoiado, percuta o ligamento patelar
logo abaixo da patela. Observe a contração do quadríceps e
a extensão do joelho. Sua mão na coxa ajuda a sentir
respostas pequenas. O Bates apresenta também posições em
decúbito dorsal para comparar respostas quando o paciente
não consegue sentar; em qualquer posição, sustente as
pernas e compare direita e esquerda.
Figura 24.53. Patelar: percussão abaixo da
patela.
Fonte: Bates, 13. ed., cap. 24, figura 24.53.
AULA PRÁTICA | EXAME NEUROLÓGICO MOTOR
Reflexos e força muscular — roteiro ilustrado pelo Bates 3
5. Reflexo aquileu — principalmente S1
Sustente o pé e faça uma dorsiflexão parcial do tornozelo
enquanto o paciente relaxa. Percuta o tendão do calcâneo e
observe ou palpe a flexão plantar do pé. A manobra pode ser
feita com o paciente sentado ou deitado, desde que o
membro esteja bem posicionado. O Bates recomenda
observar também a velocidade de relaxamento após a
contração. Se a resposta faltar, confira apoio, tensão muscular
e técnica antes de interpretá-la. Figura 24.56. Aquileu: pé sustentado em
dorsiflexão.
Fonte: Bates, 13. ed., cap. 24, figura 24.56.
Força muscular: ombro, braço e mão
6. Abdução do ombro — C5 e C6; deltoide
Peça que o paciente eleve o braço lateralmente até o nível do
ombro. Apoie-se na porção superior do braço e empurre
para baixo enquanto ele sustenta a posição. Pode-se testar
os dois braços ao mesmo tempo para comparar. Evite tomar o
movimento do tronco como força do ombro e observe se há
dor articular, que pode limitar a resposta sem representar
paresia.
Figura 24.22. Abdução do ombro contra
resistência.
Fonte: Bates, 13. ed., cap. 24, figura 24.22.
7. Flexão do cotovelo — C5 e C6; bíceps e
braquiorradial
Estabilize a parte superior do braço para que o ombro não
compense. Peça que o paciente puxe o antebraço em direção
ao braço enquanto você resiste ao movimento com a mão.
Compare os dois lados e observe se o cotovelo percorre a
amplitude esperada. O livro ilustra essa manobra ao lado da
extensão do cotovelo, que pode complementar o exame do
tríceps.
Figura 24.23. Flexão do cotovelo contra a mão
do examinador.
Fonte: Bates, 13. ed., cap. 24, figura 24.23.
AULA PRÁTICA | EXAME NEUROLÓGICO MOTOR
Reflexos e força muscular — roteiro ilustrado pelo Bates 4
8. Extensão do punho — C6, C7 e C8; nervo radial
Peça que o paciente feche a mão e mantenha o punho
estendido. Pressione a mão para baixo, tentando flexionar o
punho, enquanto ele resiste. O teste envolve os extensores
radiais longo e curto do carpo e o extensor ulnar do carpo.
Estabilize o antebraço e compare os lados. Se houver
fraqueza importante, repita sem resistência e, se necessário,
com a gravidade eliminada.
Figura 24.25. Extensão do punho contra
resistência.
Fonte: Bates, 13. ed., cap. 24, figura 24.25.
9. Extensão dos dedos — C7 e C8; nervo radial
Apoie o antebraço ou a palma da mão e solicite que o
paciente mantenha os dedos retos e estendidos. Com os
dedos da sua outra mão, tente pressioná-los para baixo,
em direção à flexão. Observe a resistência oferecida pelo
extensor dos dedos em cada lado. Diferencie esta manobra da
extensão do punho: uma pode estar mais fraca que a outra.
Figura 24.26. Dedos estendidos contra pressão.
Fonte: Bates, 13. ed., cap. 24, figura 24.26.
10. Abdução dos dedos — C8 e T1; nervo ulnar
Com a palma voltada para baixo ou a mão de lado, peça que o
paciente afaste os dedos e mantenha-os nessa posição.
Tente aproximar um dedo do outro enquanto ele resiste. A
manobra pesquisa especialmente o primeiro interósseo dorsal
e o abdutor do dedo mínimo. Compare as mãos, evitando que
o paciente compense por movimentos da mão inteira.
Figura 24.27. Dedos afastados contra pressão de
adução.
Fonte: Bates, 13. ed., cap. 24, figura 24.27.
AULA PRÁTICA | EXAME NEUROLÓGICO MOTOR
Reflexos e força muscular — roteiro ilustrado pelo Bates 5
11. Abdução do polegar — C8 e T1; nervo
mediano
Coloque o antebraço em supinação completae peça que o
paciente aponte o polegar para cima, perpendicular à
palma. Empurre o polegar para baixo, em direção à mão,
enquanto ele resiste. Assim se avalia o abdutor curto do
polegar. O teste difere da oposição e da extensão do polegar;
registre exatamente o movimento examinado. Figura 24.28. Abdução do polegar contra
resistência (crédito original MediClip/LWW).
Fonte: Bates, 13. ed., cap. 24, figura 24.28.
Força muscular: quadril, joelho e tornozelo
12. Flexão do quadril — L2, L3 e L4; iliopsoas
Com o paciente sentado ou em decúbito dorsal, coloque a
mão sobre a região média da coxa e peça que ele eleve a
coxa contra sua mão. Estabilize o tronco e compare os
lados. Esta manobra constava do corpo da transcrição,
embora não aparecesse na tabela da imagem enviada. Na
tabela original, a indicação das raízes havia variado; aqui foi
adotada a do Bates. Figura 24.29. Flexão do quadril contra a mão.
Fonte: Bates, 13. ed., cap. 24, figura 24.29.
13. Abdução do quadril — L4, L5 e S1; glúteos
médio e mínimo
Coloque as mãos na face externa dos joelhos e peça que o
paciente afaste as duas pernas contra sua resistência. O
Bates também descreve um teste contra a gravidade em
decúbito lateral, no qual o paciente eleva a perna que está
por cima. Mantenha o quadril alinhado e compare a
capacidade de mover cada lado. O esquema ao lado ilustra a
manobra principal descrita no livro.
Esquema 13, elaborado para esta aula. Vista
superior: azul indica afastar as pernas; vermelho
indica a resistência das mãos. Técnica descrita em
Bates, cap. 24.
14. Extensão do quadril — principalmente S1;
glúteo máximo
Coloque o paciente em decúbito ventral e peça que ele
levante a coxa da superfície do leito. Pressione para baixo a
face posterior da coxa enquanto ele mantém a extensão.
Observe se o tronco se arqueia para compensar e compare os
dois lados. O esquema ao lado foi criado a partir dessa
descrição do Bates.
Esquema 14, elaborado para esta aula. Vista
lateral: azul indica elevar a coxa; vermelho indica
pressão para baixo. Técnica descrita em Bates,
cap. 24.
AULA PRÁTICA | EXAME NEUROLÓGICO MOTOR
Reflexos e força muscular — roteiro ilustrado pelo Bates 6
15. Extensão do joelho — L2, L3 e L4; quadríceps
Com o paciente deitado, apoie o joelho em flexão e peça que
ele estenda a perna contra sua mão. O teste também
pode ser feito sentado, com a perna pendente. O quadríceps
costuma oferecer resistência vigorosa; estabilize a coxa e
compare a força dos dois lados. Não confunda este teste
voluntário de força com a extensão reflexa obtida após a
percussão patelar.
Figura 24.30. Extensão voluntária do joelho
contra resistência.
Fonte: Bates, 13. ed., cap. 24, figura 24.30.
16. Dorsiflexão do pé — L4 e L5; tibial anterior
Peça que o paciente puxe o pé para cima, aproximando o
dorso do pé da perna, e aplique resistência na face dorsal do
pé. Examine os dois tornozelos de maneira semelhante. Andar
sobre os calcanhares, quando seguro, complementa a
observação funcional dessa ação. Com fraqueza intensa,
avalie o movimento com menor resistência antes de graduar.
Figura 24.32. Dorsiflexão do tornozelo contra a
mão.
Fonte: Bates, 13. ed., cap. 24, figura 24.32.
17. Flexão plantar do pé — principalmente S1;
gastrocnêmio e sóleo
Peça que o paciente empurre o pé para baixo contra sua
mão, como se pisasse em um pedal, e compare os lados. O
Bates relaciona o movimento ao gastrocnêmio e ao sóleo,
com predomínio de S1. Andar na ponta dos pés, quando
seguro, complementa a avaliação. A tabela anterior não
indicava a raiz e mencionava apenas o gastrocnêmio; ambos
os dados foram completados com o livro.
Figura 24.33. Flexão plantar contra resistência.
Fonte: Bates, 13. ed., cap. 24, figura 24.33.
Roteiro de registro e consulta rápida
Ao terminar, registre a força de cada movimento de ambos os lados com grau de 0 a 5 e os reflexos
com grau de 0 a 4. Descreva assimetria, necessidade de reforço, dor, limitação de movimento e
achados associados. As raízes abaixo ajudam na localização clínica, mas cada manobra precisa ser
interpretada em conjunto com os demais músculos, sensibilidade e exame neurológico.
AULA PRÁTICA | EXAME NEUROLÓGICO MOTOR
Reflexos e força muscular — roteiro ilustrado pelo Bates 7
Teste ou reflexo Raízes no
Bates Resposta ou estrutura principal
Bicipital C5–C6 Bíceps; flexão do cotovelo
Braquiorradial C5–C6 Flexão do cotovelo e supinação
Tricipital C6–C7 Tríceps; extensão do cotovelo
Patelar L2–L4 Quadríceps; extensão do joelho
Aquileu S1 Flexão plantar reflexa
Abdução do ombro C5–C6 Deltoide
Flexão do cotovelo C5–C6 Bíceps e braquiorradial
Extensão do punho C6–C8 Extensores do carpo; nervo radial
Extensão dos dedos C7–C8 Extensor dos dedos; nervo radial
Abdução dos dedos C8–T1 Interósseo dorsal e abdutor do dedo mínimo; ulnar
Abdução do polegar C8–T1 Abdutor curto do polegar; mediano
Flexão do quadril L2–L4 Iliopsoas
Abdução do quadril L4–S1 Glúteos médio e mínimo
Extensão do quadril S1 Glúteo máximo
Extensão do joelho L2–L4 Quadríceps
Dorsiflexão do pé L4–L5 Tibial anterior
Flexão plantar do pé S1 Gastrocnêmio e sóleo
Fonte do conteúdo e das figuras
Texto-base: Transcrição: prática de reflexos e força muscular, arquivo anexado. Complementos de técnica,
graduação e raízes foram retirados de BICKLEY, Lynn S.; SZILAGYI, Peter G.; HOFFMAN, Richard M. Bates:
propedêutica médica. 13. ed. Rio de Janeiro: Guanabara Koogan, 2022. Capítulo 24, “Sistema nervoso”. Foram
utilizadas 15 figuras do livro com a numeração original. Os esquemas 13 e 14, sobre abdução e extensão do
quadril, foram elaborados para este material a partir das descrições do mesmo capítulo; eles não são figuras
reproduzidas do Bates.
CAI MEMORY 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