674 Proc. roy. Soc. Med.

Volmem 3 dy 1970 4

Meeting June 11 1969

President's Address

Trick Movements (1) Direct substitution of favourably placed

muscles: Ful abduction and elvion of the
by Group Captain C B Wynn Parry MBE DM shoulder is possible despite paralysis of deltoid,
(Central Medical Establishment, Royal Air Force, by using mucles which cross the shoulder-joint -
Kelvin House, London WIP 6A U) the long head of biceps and triceps, the pectoralis
major and the spinati.
The term 'trick movements' usually implies un-
natural movements, seen when muscles are either (2) Accessory insertion: The abductor pollicis
paralysed or inhibited for example, the hitching
- brevis and the flexor pollicis brevis inert into the
up of the shoulder by the trapezius when the extensor expansion of the thunb. It is thus
supraspinatus tendon is inflamed or the deltoid possible to extend the in_tI joint of the
paralysed. This concept has been extended to thumb when the radial or p:iior inteross
situations where prime movers are paralysed and nerves are parablsed. The abductor digiti minimi
other muscles take over their function; one is may be inserted into the volar aspect of the
exhorted to avoid them in many of the standard proximal phalanx and can thus flex the meta-
textbooks, even though useful function may be carpophalangeal joint.
obtained by such means. It is widely belived that
the encouragement of such trick movements may (3) Tendon action: This refers to the shortening of
militate asainst good function when the prime a tendon when the antagonist contracts strongly;
movers ultimately recover. Provided that the so- it occurs in muscles which cross two joints and
called trick movent does not involve abnormal have normally a limited length. Thus, when there
joint movment, putting muscles or lints to is paralysis of the long flexors of the fingers,
excessive strain, no harm can come fromtheir hyperextension of the wrist causes a tendon action
encouragement; indeed, they are of great value in at the terminal interphalangal joints due to the
the stage of weakness or paralysis. limited length of the flexors. This may look as if
the long flexors are contracting.
At the RAF Rehabilitation Units at Chessing-
ton and Headley Court, I have had under my care (4) Rebound: This refers to the phenomenon of a
a large number of patients with a variety of seeming contraction in the agonist when the
peripheral nerve disorders, and I have long been antagonist contracts strongly and then relaxes
fasinaed by the way in which the body will quickly. Strong contraction of the extensor
attempt, often most successfully, to compensate pollicis longus and sudden relaxation may look as
for muscle paralysis. Over the past fifteen years if the long flexor is working Si,in a lateral
we have studied these trick movements cliically, popliteal palsy a strong contraction ofthe platar
electromyographically and with the help of cie flexors of the toes, followed by relaxation may
film, in order to understand their mechanism, to look as ifthe toe extensors are contracting.
avoid diagnosing recovery whe movemet is due
to a trick action, and to teach patients how to use (5) Anomalous nerve supply: In 20 % of all normal
these movements for function when prime movers subjects there is anomalous nerve supply in the
are paralysed. hand. The commonest anomals are ular supply
of the opponens, the second lunbrical and the
I would suggest the following classification of flexor pollicis brevis. Cues of complete ulnar or
trick movemets: (1) Direct substitution of complte median supply of all the ininsics have
favourably placed muscles. (2) Accessory inser- been described. These motor aalis may or
tion. (3) Tendon action. (4) Rebound. (5) may not be associated with an a ly of sensory
Anomalous nerve supply. (6) Gravity. I do not supply and are not n bilateral or sym-
claim that this is an exhaustive classification, but metrical. It is wise to stimulte the ulnar and
it accounts for all those that I have seen. Eamles median nerves at both the wrist and the elbow in
of each of these groups are given below. all cases of nerve injuries, to makie sure there is no
5 Section ofPhysical Medicine 675
anomaly present. It is surprising how often angeal joint of the thumb, because the short
median nerve lesions can be confusing. Despite abductor and short flexor have an insertion into
the appearance of complete severance of the the extensor expansion. This can readily be seen
nerve at operation, in some 20% of cases clear because the patient has to bring the thumb into
activity is seen in opponens or the third lumbrical. palmar abduction before the interphalangeal joint
It is then important to distinguish whether this is a can extend.
partial lesion with an aberrant branch or an actual
anomaly of supply. This can be done by nerve When a patient attempts to extend the meta-
stimulation, and is an essential part of the clinical carpophalangeal joints the interphalangeal joints
examination. It has been well established that will extend, thus pulling on the extensor expan-
fibres from the median nerve may cross over to sion and therefore flexing the metacarpophalan-
the ulnar nerve in the forearm and vice versa; geal joints. In general, it is a useful sign that
therefore in cases of doubt, quantitative EMG attempts to activate a muscle that is paralysed
studies are valuable, recording amplitudes to result in the opposite movement either through
supramaximal stimulation with surface electrodes pull on the same insertion from a different direc-
over the hypothenar and thenar eminences and tion, as in this case, or through rebound.
stimulating the ulnar and median nerves at both
elbow and wrist. Sometimes the wrist appears to extend when
the patient relaxes after flexing the fingers and
(6) Gravity: Wood Jones in his classic book 'The wrist strongly. This is an extreme example of the
Principles of Anatomy as Seen in the Hand' rebound phenomenon.
(1942) pointed out that muscles will always allow
gravity to effect a movement if given the chance. Ulnar Nerve
The elbow can easily be extended by gravity when In a complete ulnar nerve lesion the adductor of
the triceps is paralysed provided the shoulder is the thumb is paralysed and attempts to bring the
below 90 degrees. In order to avoid the trick thumb to the index finger, with the forearm held
action of gravity the shoulder must be held at 90 with the radial aspect pointing to the ground in
degrees or higher. If the triceps is paralyzed the order to eliminate gravity, result in marked
shoulder depressors will come into action until the flexion of the interphalangeal joint. This trick
arm is below 90 degrees, when gravity will extend action of the long flexor is known as Froment's
the arm. Similarly, the thumb can be adducted to sign.
the palm by gravity and therefore the hand must
be held with the ulnar border uppermost in order The interossei are the abductors and the
to test adductor pollicis. adductors of the fingers. However, the long
extensors, when they contract strongly, can give
Peripheral Nerve Lesions the appearance of some abduction; similarly, the
In each individual nerve lesion there is a clearly long flexors can give some adduction. If the hand
defined pattern of trick movements. It is valuable is laid flat palm down on the table and the middle
to know these, for their presence will confirm the finger is raised, the long extensor is now fully
nature of the nerve lesion, while their absence will occupied in maintaining the finger in the air
cast serious doubt on the diagnosis. against gravity. Side-to-side movement will then
be done solely by the interossei. In a complete
In an organic nerve lesion, trick movements are ulnar nerve lesion this will not be possible;
instinctively produced to attempt some sort of instead of the finger moving from side to side the
function and these are not seen in cases of whole hand moves from side to side in a character-
hysterical paralysis. Moreover, the first sign of istic fashion, while the finger is kept still. This
recovery in a known lesion of a peripheral nerve test should be done with the index and ring
is the absence of a trick movement; this dis- fingers only, because the little and index fingers
appearance of a trick movement precedes the have two extensor tendons, so that one can move
appearance of contraction in the recovering prime the finger sideways while the other supports it
mover and is thus a useful sign of reinnervation. against gravity.
The appreciation of the mode of action of trick
movements will also help one to position the limb Median Nerve
or hand by 'lively' splints so as to get the most When the patient with a complete median nerve
value from these trick actions for function. lesion attempts to oppose the thumb to the little
finger he cannot bring the thumb away from the
Radial Nerve hand, as the short abductor and the opponens are
In a complete radial nerve lesion it is always paralysed. He therefore flexes the interphalangeal
possible for the patient to extend the interphal- joint of the thumb in an attempt to oppose. This
676 Proc. roy. Soc. MAh Voume63JAdy 1970 6
trick movematsiused for function in ianCS-7Lesions
nerve lsons by put,ing the thumb in a livey Patiets who have comtpet paralyss of the
splint which spr the ntmb in palmar elbow flexors and the bcoa X ale
abduion, tbus putti the long flexor in an to beid the elbow. This is achieved by fist .pro-
adv position to give some opposition tonating t-he forearm, ext ig the wrinted ing
the finger tips. the fingers. This uss the rever action of olong
flexors and extensors, which now act fr*-thei
insertion to their origin on the nWdial and latrl
Muscu4ocwtaneos Nerve epicondyles. The Steindler opetion use the
In complete leions of this ner it is still possible principle of this trick action by moving the fexor
to flex theelbow by brachioadialis. To do so the origin furh up the humerus to increase the
patient has to bring the forearm to the mid mechanical advantage.
position. This can be a powerful movement, and
patients can lift weights of up to 10 lb (4'5 kg).
LowerLimb
Trick movements in the lower limb are less dram-
Circumtflex Nerve atic because the leg, being wei*tbesin and
With complte paralysis of the deltoid full abduc- working against gravity, needs consideable
tion and elevation is possible. It is achieved by power for function.
first externally rotating the humerus by infra- In a complete lateral popliteal nenre palsy,
spinatus; this moves the axis of the shoulder joint strong flexion of the toes, followed by raxation
out externally so that the clavicular head of can, by rebound, give the impon of full
pectoralis major now acts as an abductor; it is extension.
reinforced by the long heads of biceps and triceps We have seen a patient with complete paralysis
which also cross the joint. of glutei and quadriceps on one side, who was
With taining, patients can achieve very power- able to walk without calipers or sticks H. hitche
ful function and are often as strong on the the pelvis up by contracting the qatus lum-
paralysed side as on the normal side. borum and achieved knee flexion by rebound of
the gastrocnemius.
In complete paralysis of the qadries the
C5-6Lesions sartorius and tensor fascia lat can act as efficimt
If the infraspinatus is paralysed as well as the knee extensors; in walking, this action can be
deltoid, then it is no longer possible to elevate the combined with the rebound of the _
armand the patient can only hitch up the shouldr to give knee extension.
using the trapezius. The is tested by I believe that trick movements deserve serious
asking the paticnt to extemally rotate the forearm study, for they can yield fascinatingformaton
when it is held by the side with the elbow flexed about muscle function and can alo be of geat
to 90 degres. In complte paralysi of this musle functional value either by thmslvWes, or in
the patient will, dorsiflex the wrist, and this trick combination with appropriate spinting or
action is a valuable sign of paralysis of this reconstructive surgery.
muscle.
It is sometimes possible to give a patient some
abduction by transferring the inrtion of the Acknowledgment: I am grateful to DGMS (RAF)
la£issimus dorsi into theinsrtion of infraspinatus. for pennission to publish this paper.
This will allow the patient to rotate the humeus
externally so that he can usethe pectoralis and [The various trick movements described were
loig heads of triceps and biceps to abduct. illustrated by a film.]