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MotorPathways
byAnnieBurkeDoe,PT,MPT,PhD
PracticingphysicaltherapistandassociateprofessorattheUniversityofSt.AugustineforHealthSciencesinSan
Diego,California

Slide1:MotorPathways

WelcometoNeuroanatomyinPhysicalTherapy.I'mDr.AnnieBurkeDoe,apracticingphysicaltherapistandan
associateprofessorattheUniversityofSt.AugustineforHealthSciencesinSanDiego,California.Inthislecture,
wewillbelookingattheorganizationofthemotorsystem,specifically,thecorticospinaltractandothermotor
pathways.Attheendofthissection,youshouldbeableto:describetheanatomyandfunctionsofthespinalcord
includingnucleiandlaminaediscussspinalcordbloodsupplyidentifythesiteoforigin,decussation,andlevelsof
terminationforthecorticospinaltractandothermotorpathwaysdescribetheautonomicnervoussystem,division,
fibers,neurotransmitters,andregulationdifferentiateupperandlowermotorneuronsinthenervoussystemand
describecommongaitdisordersinneurology.

Slide2:PrimarySensoryandMotorAreas


Here,inslide2,theprimarysensoryandmotorareasareshown.Rememberthattheseareasarelocatedoneither
sideofthecentralsulcus,whichdividesthefrontallobefromtheparietallobe.Theprimarymotorcortexinredis
intheprecentralgyruswhiletheprimarysensorycortexisinthepostcentralgyrus.Thereareseveralimportant
areasofmotorassociationcortexthatliejustanteriortotheprimarymotorcortexincludingthesupplementalmotor
areaingreenandthepremotorcortexinorange.Theseregionsareinvolvedinhigherordermotorplanningand
projecttotheprimarymotorcortex.Similarly,somatosensoryassociationcortexintheparietallobereceivesinputs
fromtheprimarysomatosensorycortexandisalsoimportantinhigherordersensoryprocessing.

Slide3:SomatotopicOrganization


Functionalmappingandlesionstudieshavedemonstratedthattheprimarymotorandsomatosensorycorticesare
whatisdescribedassomatotopicallyorganized.Somatotopicorganizationensuresthatinformationfromaspecific
areaofthebodyisrepresentedinaspecificareaofthecortex.Fibersinapathwayarearrangedsothatinformation
fromthelowerpartofthebodytravelsinaparticularpathwayorpartofthecentralnervoussystemthatisdifferent
frominformationfromtheupperpartsofthebody.Forexample,informationrelatedtothelowerpartofthebody
travelsinfiberslocatedmediallyinthewhitematterofthespinalcordwhilethosefromtheupperpartofthebody
travelinfiberslocatedatthelateralparts.Thus,thepathwayissaidtohavesomatotopicorspatialorientation.This
spatialorientationensuresthatthepointoforiginofthesignalismaintainedallthewaytothefinalpointof
terminationofthepathway.Let'slookatthismoreclosely.

Slide4:Sensory&MotorHomunculus


Thecorticalmapsdepictedhereontheleft,thesensoryhomunculus(homunculusmeaning"littleman"inLatin),
and,ontheright,themotorhomunculusweredevelopedtoassistusinunderstandingbroadlythatregionsofthe
cortexcorrespondtoregionsinthebody.Thesedepictionsareusedtoassistusforclinicallocalizationofcortical
function.Theresultingimageisagrotesquelydisfiguredhumanwithdisproportionatelyhugehands,lips,andface
incomparisontotherestofthebody.Becauseofthefinemotorskillsandsensenervesfoundintheseparticular
partsofthebody,theyarerepresentedasbeinglargeronthehomunculus.Apartofthebodywithfewersensory
and/ormotorconnectionstothebrainisrepresentedtoappearsmaller.

Slide5:SpinalCord


Whenlookingatspinalcordanatomy,thecordisdividedintograymatter,depictedhereontheleft,and
surroundingwhitematter.Thespinalcordcontainsan"H"orbutterflyshapedcentralgraymattersurroundedby
ascendinganddescendingwhitemattercolumns,alsocalledfuniculi.Sensoryneuronsinthedorsalrootganglia
haveaxonsthatbifurcate.Onebranchconveysthesensoryinformationfromtheperiphery,andtheothercarriesthe
informationthroughthedorsalnerverootfilamentsintothedorsalaspectofthespinalcord.Thecentralmatterhas
adorsalposteriorhornthatisinvolvedmainlyinsensoryprocessinganintermediatezonethatcontains
interneuronsandcertainspecializednucleiandaventralhorn,oranteriorhorn,thatcontainsmotorneurons.Motor
neuronssendtheiraxonsoutofthespinalcordviatheventralnerverootfilaments.Thespinalgraymattercanalso
bedividedintonucleiorusingadifferentnomenclatureintralaminar,namedbyBrorRexed,withdifferent
functionsthatwillbediscussedlater.Thespinalcordwhitematterconsistsofdorsalposteriorcolumns,lateral
columns,andventralanteriorcolumns.

Slide6:SpinalCord


Alongitslength,thespinalcordvariesinsizeandshape.Thewhitematter,madeupoflongitudinaltracts,is
thickestinthecervicallevelhereatthetopwheremostascendingfibershavealreadyenteredthecordandmost
descendingfibershavenotyetterminatedontheirtargets,whilethesacralcordismostlygraymatter.Inaddition,
thespinalcordhastwoenlargements:thecervicalenlargementandthelumbosacralenlargement,whichgiveriseto
thenerveplexusforthearmsandlegs,respectively.Thespinalcordhasmoregraymatteratthecervicaland
lumbosacrallevelsthanatthethoraciclevels,particularlyintheventralhorns.Inthethoraciccord,alateralhornis
presentedthatcontainstheintermediolateralcellcolumns.Theintermediolateralcellcolumnsexistatvertebral
levelsT1toL2andmediatetheentiresympatheticinnervationofthebody.

Slide7:BloodSupplytotheSpinalCord


Thebloodsupplytothespinalcordarisesfrombranchesofthevertebralarteriesandthespinalradiculararteries.
Thesevertebralarteriesgiverisetotheanteriorspinalarterythatrunsalongtheventralsurfaceofthespinalcord.
Inaddition,twoposteriorspinalarteriesarisefromthevertebralorposteriorinferiorcerebellararteriesandsupply
thedorsalsurfaceofthecord.Theanteriorandposteriorspinalarteriesarevariableinprominenceatdifferent
levelsandformaspinalarterialplexusthatsurroundsthespinalcord.Thirtyonesegmentalarterialbranchesenter
thespinalcanalalongitslength.Mostofthebranchesarisefromtheaortaandsupplythemeninges.Only6to10of
thesereachthespinalcordasradiculararteries,arisingagainatvariablelevels,dependingontheperson.Thegreat
radiculararteryofAdamkiewicz,typicallyaprominentarteryarisingfromtheleftsideanywherefromT5toL3but
typicallyseenbetweenT9andT12,providesthemajorbloodsupplytothelumbarandsacralcord.Themid
thoracicregion,approximatelyT4toT8,liesbetweenthelumbarandvertebralarterysupplyandisavulnerable
zoneofrelativelydecreasedperfusion.Thisregionisverysusceptibletoinfarctionduringthoracicsurgeryorother
conditionscausingdecreasedaorticpressure.Theanteriorspinalarterysuppliesapproximatelytheanteriortwo
thirdsofthecordincludingtheanteriorhornsandtheanteriorlateralwhitemattercolumns.Theposteriorspinal
arteriessupplytheposteriordorsalcolumnandpartoftheposteriorhorns.

Slide8:MotorSystems


Whenwethinkaboutthecomplexityofmovementrequiredforathleticperformance,playinganinstrument,or
otherskilledmovement,wecanunderstandthatmotorsystemsinvolveelaboratenetworksorneuronalcircuitsthat
communicatethroughmanyhierarchicalfeedbackloops.Asummaryofmotorsystemsarepresentedherewithonly
theprincipalmotorloopsdepictedandtheimportantsensoryinputsomitted.Rememberthatthecerebellumandthe
basalganglia,pictured,participateinthesefeedbackloopsandprojectbacktothecerebralcortexviathethalamus.
Theydonotthemselvesprojecttolowermotorneurons.Previously,wediscussedthatwithinthecerebralcortex
itselfarenumerousmotorcircuitsformotorcontrol,andtheyprojecttothebasalgangliapicturedhereinblue.The
basalgangliaareamassivegraymatterthatlieswithineachhemispheredeeptothefloorofthelateralventricles.
Theyareembeddedinwhitematterthatprojectsthroughthethalamusbacktothecortex.Thebasalgangliaare
involvedwithsubconsciouscontrolofskeletalmuscletoneandthecoordinationoflearnedmovementpatterns.
Undernormalconditions,thesenucleidonotinitiateparticularmovements,butoncethemovementhasstarted,
theyaregoingtoprovidegeneralpatternandrhythm,especiallyforthetrunkandtheproximallimbmuscles.
Cerebralareas,includingassociationcortexregionssuchasthesupplementarymotorarea,premotorcortex,and
parietalassociationcortex,arecrucialtoplanningandformulationofmotoractivities.Lesionsoftheseregionsof
associationcortexcanleadtowhatwecallapraxia,inwhichthereisadeficitofhigherordermotorplanningand
execution,despitenormalstrength.Cerebellarfeedbackloopsassistwithprogrammingandfinetuningof
movementscontrolledattheconsciousandsubconsciouslevels.Thecerebellumrefineslearnedmovementpatterns
bycomparingmotorcommandswithproprioceptiveinformationandperformsadjustmentsneededtomake
movementssmooth.Damagetotheseareascancausewhatwecallataxia,orlackoforder,adisturbanceofmuscle
coordination.

Slide9:UpperMotorandLowerMotorNeurons


Recallthatsomaticmotorpathwaysinvolveatleasttwomotorneurons:anuppermotorneuron,whosecellbody
liesinacentralnervoussystemprocessingcenter,andalowermotorneuron,depictedhereinblue,whosecellbody
liesinanucleusofthebrainstemasitrelatestocranialnervesorinthespinalcordasitrelatestoperipheral
nerves.Theuppermotorneuronsynapsesonthelowermotorneuronandinnervatesasinglemotorunitinaskeletal
muscle.Activityintheuppermotorneuronmayfacilitateorinhibitthelowermotorneuron.Activationofthelower
motorneurontriggersacontractionintheinnervatedmuscle.Onlytheaxonofthelowermotorneuronextends
outsidetheCNS.Destructionordamagetoalowermotorneuronwilleliminatevoluntaryandreflexcontrolover
theinnervatedmotorunit.

Slide10:PrimaryDescending(Motor)Pathways


Thistabledescribestheprimarydescendingmotorpathwaysbylocationofuppermotorneurons,destination,side
ofcrossoverordecussation,andtheirroleinmotorfunction.Descendingmotorpathwayscanbedividedinto
lateralandmedialmotorsystemsbasedontheirlocationinthespinalcord.Thetwolateralmotorsystemsarethe
lateralcorticospinaltractandtherubrospinaltract,whichcontrolmovementsoftheextremities.Thelateral
corticospinaltractinparticularisessentialforrapiddexterousmovementatindividualdigitsorjoints.Mostof
thesepathwayscrossoverfromtheirsiteoforiginanddescendinthecontralateralspinalcordtocontrol
contralateralextremities.Thatiswhytheleftsideofthebraincontrolstherightsideofthebody.Thefourmedial
motorsystemsaretheanteriorcorticospinaltract,thevestibulospinaltract,thereticulospinaltract,andthe
tectospinaltract.Thesepathwayscontrolproximalaxialandgirdlemusclesinvolvedinposturaltone,balance,
orientingmovementsoftheheadandneck,andautomaticgaitrelatedmovements.Themedialmotorsystems
descendipsilateralorbilaterally.Somedescendonlytotheupperfewcervicalsegments,aswewillseedepictedin
thefollowingslides.Themedialmotorsystemstendtoterminateoninterneuronsthatprojecttobothsidesofthe
spinalcord,controllingmovementsthatinvolvemultiplebilateralspinalsegments.Becauseofthis,unilateral
lesionsofthemedialmotorsystemsproducenoobviousdeficits.Therubrospinaltractinhumansissmall,andits
functionisnotwellunderstood.Itisthoughttoplayaroleinmotorfunctionaftercorticospinaltractinjuryandin
flexorordecorticateposturingoftheupperextremities,whichisseenwithlesionsabovetheleveloftherednuclei.

Slide11:SomatotopicOrganizationofMedialandLateralMotorSystemProjectionstoAnteriorHornCells


Whenwelookatthesomatotopicorganizationofthespinalcord,hereweareseeingthemedialandlateralmotor
systemsprojectingtoanteriorhorncells.Ourlateralmotorsystemscorticospinalandrubrospinaltractsinred
projecttothelateralanteriorhorncells,whilethemedialmotorsystemsanteriorcorticospinal,vestibulospinal,
reticulospinal,andtectospinalinblueprojecttothemedialanteriorhorncells.Lateralanteriorhorncellscontrol
distalmusclesoftheextremitywhilemedialanteriorhorncellscontrolproximaltrunkmusculature.

Slide12:CorticospinalTract

Let'snowtakealookatthedescendingmotortracts.Thecorticospinaltractisaclinicallyimportantdescending
motorpathwaythatconsistsofalateralandananteriorportion.Thispathwayissometimescalledthepyramidal
systembecauseofitsrelationshiptothemedullarypyramids.Thecorticospinaltractprovidesvoluntarycontrol
overskeletalmuscles.Thissystembeginsinthepyramidalcellsoftheprimarymotorcortex,andtheaxonsofthese
uppermotorneuronsdescendintothebrainstemandspinalcordtosynapseonlowermotorneurons,depictedin
red,thatcontrolskeletalmuscles.

Slide13:CorticospinalTract

Whenlookingatthepathwayofthecorticospinaltract,overhalfofthefibersoriginateintheprimarymotorcortex,
Brodmannarea4,oftheprecentralgyrus.Theremainderarisefromthepremotorandsupplementalmotorarea6,or
fromtheparietallobeareas3,1,2,5,and7.Theprimarymotorcortexneuronscontributingtothecorticospinal
tractarelocatedmostlyincorticallayer5.Layer5pyramidalcellprojectionsynapsesdirectlyontomotorneurons
intheventraloranteriorhornofthespinalcord,aswellasontospinalinterneurons.About3%ofcorticospinal
neuronsaregiantpyramidalcellscalledBetzcells,whicharethelargestneuronsinthehumannervoussystem.
Axonsfromthecortexentertheupperportionsofthecerebralwhitematterorthecoronaradiataanddescend
towardtheinternalcapsule.Rememberthatinadditiontothecorticospinaltract,thecerebralwhitematterconveys
bidirectionalinformationbetweendifferentcorticalareasandbetweencortexanddeepstructures,suchasthebasal
ganglia,thethalamus,andthebrainstem.Thesewhitematterpathwaysformafanlikestructureastheyenterthe
internalcapsule,whichcondensesdowntofewerandfewerfibersasconnectionstodifferentsubcorticalstructures
aremade.Let'scontinuetofollowthetractoverthenextfewslides.

Slide14:InternalCapsule


Again,thecorticospinaltractbeginsinthemotorcortexanddescendsintotheinternalcapsule.Theinternal
capsule,orprojectionfibers,linkthecortextothediencephalon,thebrainstem,thecerebellum,andthespinalcord.
Allprojectionfibersmustpassthroughthediencephalonwhereaxonsascendingtosensoryareasofthecortexpass
amongtheaxonsdescendingfrommotorareasofthecortex.Theinternalcapsuleisbestappreciatedinthis
horizontalbrainsection,inwhichtherightandleftinternalcapsuleslooklikearrowheads,hereinred,ortwoletter
"V"swiththeirpointsfacingeachother.Note,thatthethalamusandcaudatenucleusarealwaysmedialtothe
internalcapsule,whiletheglobuspallidusandtheputamenarealwayslateraltotheinternalcapsule.

Slide15:InternalCapsule


Hereisaschematicrepresentationofthehorizontalviewshowingthethreepartsoftheinternalcapsule:the
anteriorlimbontop,theposteriorlimbonthebottom,andthegenu.Notethattheanteriorlimboftheinternal
capsuleseparatestheheadofthecaudatefromtheglobuspallidusandputamenwhiletheposteriorlimbseparates
thethalamusfromtheglobuspallidusandtheputamen.Thegenu,or"knee"inLatin,isthetransitionbetween
anteriorandposteriorlimbsattheleveloftheforamenofMonro.Thecorticospinaltractliesintheposteriorlimb
oftheinternalcapsule,andyoucanseethatthesomatotopicmapispreservedsofibersoftheface,"F,"aremore
anterior,andthoseofthearm,letter"A,"andleg,letter"L,"areprogressivelymoreposterior.Fibersprojecting
fromthecortextothebrainstem,includingmotorfibersfortheface,arecalledcorticobulbarinsteadof
corticospinalbecausetheyprojectfromthecortextothebrainstemorbulb.Despitethissomatotopicarrangement,
thefibersoftheinternalcapsulearecompactenoughthatlesionsatthislevelgenerallyproduceweaknessofthe
entirecontralateralbodyface,arm,andleg.

Slide16:CorticospinalTract


Aswecontinuedescendingfromtheinternalcapsule,thecorticospinaltractsmeetthecerebralpeduncles,orfeetof
thebrain.Thewhitematterislocatedintheventralportionofthecerebralpedunclesandiscalledthebasis
pedunculi.Thecorticospinaltractfibers'necksdescendthroughtheventralpons.Theseformthemedullary
pyramids.Again,forthisreason,thecorticospinaltractissometimesreferredtoasthepyramidaltract.The
transitionfromthemedullatothespinalcordiscalledthecervicomedullaryjunctionandoccursatthelevelofthe
foramenmagnum.Atthispoint,about85%ofthepyramidaltractfiberscrossoverinthepyramidaldecussationto
enterthelateralwhitemattercolumnsofthespinalcordformingthelateralcorticospinaltract.Asomatotopic
representationispresentinthelateralcorticospinaltract,withfiberscontrollingtheupperextremitylocated
mediallytothosecontrollingthelowerextremity.Finally,theaxonsinthelateralcorticospinaltractenterthespinal
cordcentralgraymattertosynapseontoanteriormotorhorncells.Theremainingapproximately15%ofthe
corticospinalfiberscontinueintothespinalcordipsilateralwithoutcrossingandentertheanteriorwhitematter
columnstoformtheanteriorcorticospinaltract.

Slide17:DescendingMotorPathways


Again,herewecanseethelateralcorticospinaltractpathway,aswellastherubrospinaltract,whichareresponsible
forcontralateralmotorfunction.Note,ontheright,therubrospinaltractissmallinhumansandterminatesinthe
cervicalcord.Itisthoughttoberesponsiblefortakingoverfunctionsaftercorticospinaltractinjuryandmayalso
playaroleinflexorordecorticateposturingintheupperextremitieswithlesionsabovetheleveloftherednucleus
inwhichtherubrospinaltractispreserved.

Slide18:DescendingMotorPathways

Onthisslide,wehaveonthelefttheanteriorcorticospinaltractterminatingatthecervicalandupperthoraciccord,
andithascontrolofthebilateralaxillaandgirdlemuscle,andontheright,thevestibulospinaltractwithmedial
fibersterminatinginthecervicalandupperthoraciccordandlateralportions,whicharestillconsideredpartofthe
medialsystem,terminatingintheentirecord.Vestibulospinaltractsareresponsibleforpositioningoftheheadand
neck(themedialfibers)andbalance(thelateralfibers).

Slide19:DescendingMotorPathways

Thefinaltwodescendingmotorpathwaysarethetectospinaltract,terminatinginthecervicalcord,andthe
reticulospinaltract,terminatingalongtheentirecord.Thetectospinaltractisresponsibleforcoordinationofhead
andeyemovements,andthisispoorlyunderstoodinhumans.Thereticulospinaltractisresponsibleforautomatic
postureandgaitrelatedmovements.

Slide20:TheAutonomicNervousSystem(ANS)


Incontrasttothesomaticmotorpathwaysdescribedintheprecedingslides,theautonomicnervoussystem
generallycontrolsmoreautomaticandvisceralbodyfunctions.Theautonomicefferentsareuniqueanatomically.
Thereisaperipheralsynapselocatedinaganglionthat'sbetweenthecentralnervoussystemandtheeffectorgland,
orsmoothmuscle.Therearesensory(afferent)inputstotheautonomicnervoussystem,bothcentrallyandinthe
periphery.However,theautonomicnervoussystemitselfconsistsofonlyefferentpathways.

Slide21:ANSDivisions

Theautonomicnervoussystemhastwomaindivisions:thesympathetic,alsocalledthoracolumbar,whicharises
fromthoraciclevel1tolumbarlevel2or3.Thesympatheticdivisionispicturedhereontheleftsideoftheslide
andisinvolvedmainlyin"fightorflight"functions,suchasincreasingheartrateandbloodpressure,
bronchodilation,andincreasingpupilsize.Theothermaindivision,theparasympatheticdivision,alsocalledthe
craniosacraldivision,incontrastarisesfromcranialnervenucleiandfromsacrallevels2through4,anditis
involvedinthe"restanddigest"functions,suchasincreasinggastricsecretionsandperistalsis,slowingtheheart
rate,anddecreasingthepupilsize.Theentericnervoussystemisconsideredathirddivisionoftheautonomic
nervoussystemconsistingofaneuralplexuslyinginthewallsofthegutthatisinvolvedincontrollingperistalsis
andgastrointestinalsecretions.Preganglionicneuronsofthesympatheticdivisionformachaincalledthe
sympathetictrunk,picturedinred.Thesympathetictrunkrunsallthewayfromcervicaltosacrallevelsoneach
sideofthespinalcord.Thesympathetictrunkallowssympatheticefferents,whichexitonlyatthoracolumbar
levels,toreachotherpartsofthebodyaswell.Parasympatheticpreganglionicfibersarisefromcranialnerve
parasympatheticnucleiandfromsacralnerveparasympatheticnucleiandarelocatedingraymatterofS2,3,and4.

Slide22:AutonomicMotorFibers

Herewecanseethesomaticmotorsysteminpinkcomparedwiththeautonomicsympatheticvisceralmotor
efferentsinblue.Preganglionicneuronsofthesympatheticdivisionarelocatedinanintermediolateralcellcolumn
inlamina7ofthespinalcordatlevelsT1toL2or3.Withsympatheticstimulation,efferentmotorcommandswill
traveltothesympatheticgangliathatinnervatepostganglionicfiberstosmoothmuscles,glands,andorgans.

Slide23:ANSNeurotransmitters


Whenlookingatautonomicnervoussystemneurotransmitters,synapticneurotransmissionincholinergic
preganglionicneuronsinboththesympatheticandparasympatheticgangliaismediatedbytheneurotransmitter
acetylcholineatnicotinicreceptors.Thesympatheticandparasympatheticsystemsdifferintermsoftheirpost
ganglionicneurotransmitters.Inthesympatheticpostganglionhereatthetop,neuronsreleasepredominantly
norepinephrineontoendorgansourtargettissueandactivateadrenergicalphaorbetareceptors.
Parasympatheticpostganglionicneurons,hereatthebottom,releasepredominantlyacetylcholine,andactivate
muscariniccholinergicreceptorsatendorgans.Noradrenergicoradrenergicalpha1,alpha2,beta1,beta2,and
beta3subtypes,andcholinergicmuscarinic1,muscarinic2,andmuscarinic3receptorsubtypesmediatedifferent
actionsoftheseneurotransmittersonendorgans.Onenotableexceptiontothenorepinephrines
sympathetic/acetylcholineparasympatheticruleisforpostganglionicneurotransmittersatsweatglands,whichare
innervatedbysympatheticpostganglionicneuronsthatreleaseacetylcholine.

Slide24:ANSRegulation


Whenlookingattheautonomicnervoussystemanditsregulation,sympatheticandparasympatheticoutfloware
controlledbothdirectlyandindirectlybyhighercentersincludingthehypothalamus,brainstemnucleisuchasthe
nucleussolitarius,theamygdalaofthelimbicsystem,andseveralotherregionsoflimbiccortex.Autonomic
responsesarealsoregulatedbyafferentsensoryinformationincludingsignalsfrominternalreceptorssuchas
chemoreceptors,osmoreceptors,thermoreceptors,andbaroreceptors.Thisregulationwilladjustandcoordinatethe
activitiesoftheautonomiccentersthatarelocatedintheponsandthemedullathatregulateheartrate,blood
pressure,respiration,anddigestion.Itshouldalsobenotedthatparasympatheticandsympatheticfunctionseach
haveuniquelocationsinthehypothalamus.

Slide25:UpperMotorNeuronvs.LowerMotorNeuron


Theconceptofuppermotorneuronversuslowermotorneuronisveryusefulclinically.Specificsignsare
associatedwithuppermotorneuronandlowermotorneuronthatassistthelocalizationoflesions.Rememberthat
uppermotorneuronofthecorticospinaltractprojectfromthecerebralcortextolowermotorneuronlocatedinthe
anteriorhornofthespinalcord.Lowermotorneuronsinturnprojectviaperipheralnervestoskeletalmuscles.An
identicalconceptappliestothecorticobulbartractandcranialnervemotornuclei.Signsoflowermotorneuron
lesionincludemuscleweakness,atrophy,fasciculations,andhyporeflexia.Fasciculationsareabnormalmuscle
twitchescausedbyspontaneousactivityingroupsofmusclecells.Anexampleofabenignfasciculation,not
associatedwithmotorneurondamage,istheeyelidtwitchingoftenexperiencedafterperiodsoffatigue,excess
caffeine,andeyestrainsuchasreadingforlongperiodsoftime.Signsofuppermotorneuronlesionsinclude
muscleweaknessandacombinationofincreasedtoneandhyperreflexia,sometimesreferredtoasspasticity.
Spasticityisaninvoluntaryvelocitydependentincreaseintonethatresultsinmuscleresistancetomovement.

Slide26:TermsCommonlyUsedtoDescribeWeakness


Weaknessisoneofthemostimportantfunctionalconsequencesofbothupperandlowermotorneuronlesions.
Varioustermsareusedandmaybeusedinterchangeablyinclinicalpracticetodescribeboththeseverityand
distributionoftheweakness.Paresisisdefinedasweaknessorpartialparalysis.Anexamplewouldbehemiparesis,
andclinicallyyouwouldseeweaknessononesideofthebody.Plegiaisdefinedasnomovement.Anexample
wouldbehemiplegia,andclinicallyyouwouldseenomovementononesideofthebody.Paralysisisalsodefined
asnomovement.Anexamplewouldbearmparalysiswithnomovementofthearm.Palsyisalessprecisetermfor
weaknessornomovement.Anexamplewouldbeafacialpalsywithweaknessorparalysisofthefacemuscles.
Termsdenotinglocationincludehemi,meaninghalforonesideofthebodyparameaningbothlegsmono
meaningonelimbdimeaningbothsidesofthebodyequallyaffectedandquadriortetrameaningfourlimbs
involved.

Slide27:LocalizationofCommonGaitDisorders


Gaitdisorderscanbecausedbyabnormalfunctioninalmostanypartofthenervoussystem,aswellasbysome
orthopedicconditions.Carefulexaminationofgaitisthereforeoneofthemostsensitivetestsofsubtleneurologic
dysfunction.Characteristicdisordersofgaitcanbeseenwithlesionsinspecificsystems.Spasticgaitcanbe
unilateralorbilateralcorticospinaltractinvolvementandappearsasstiffleggedcircumduction,sometimes
scissoringofthelegsandtoewalking,adecreasedarmswing,unsteadyfallingtowardoneside,andcanbeseenin
cortical,subcortical,brainsteminfarctsaffectinguppermotorneuronpathwayscerebralpalsydegenerative
conditionsmultiplesclerosisandspinalcordinjury.Ataxicgaitcanbelocalizedtothecerebellarvermisorother
midlinecerebellarstructuresappearingaswidebasedgait,unsteadiness,staggeringsidetoside,fallingtowardthe
worsesideofthepathology.AsubtledeficitmaybedetectedwiththetandemRombergtestordrunkwalk.
Vertiginousgaitislocalizedinthevestibularnuclei,vestibularnerve,orthesemicircularcanals.Lookingsimilarto
anataxicgait,widebasedandunsteady,patientswillswayandfallwhenaskedtostandwiththeirfeettogetherand
theireyesclosed,whichiscalledtheRombergsign.Frontalgaitinvolveslesionslocalizedinthefrontallobesor
frontalsubcorticalwhitematterandpresentsasslow,shufflingneuroorwidebased"magnetic"barelyraising
thefeetoffthefloorandthensteady,sometimesresemblingParkinsoniangait.Parkinsoniangaitcanbelocalized
inthesubstantianigraorotherregionsofthebasalgangliaandpresentsasslow,shuffling,andnarrowbased.The
clientwillhavedifficultyininitiationofmovementandoftenwillbestoopedforwardwithdecreasedarmswing
andenblocturning.Theyareunsteadywithretropulsion,whichistakingseveralstepsbackwardtoregainbalance
whenpushed.

Slide28:LocalizationofCommonGaitDisorders


Dyskineticgaitcanoftenbelocalizedinthesubthalamicnucleusorotherregionsofthebasalganglia.Itcan
presentasunilateralorbilateraldancelike(choreic),flinging(ballistic),orwrithing(athetoid)movementsthat
occurduringwalkingandmaybeaccompaniedbyunsteadiness.CommoncausesareHuntington'sdisease,infarcts
ofthesubthalamicnucleusorstriatum,asasideeffectoflevodopaorotherfamilialordruginduceddyskinesias.
Tabeticgaitcanbelocalizedintheposteriorcolumnsofsensorynervefibersandpresentsashighstepping,foot
flappinggaitwithparticulardifficultywalkinginthedarkoronunevensurfaces.Thepatientsswayandfallwith
attemptstoperformtheRombergsign.Posteriorcordsyndromeandseveresensoryneuropathymaybecausative.

Slide29:ClinicalCase1


Thefollowingclinicalcaseshavebeendevelopedforyourreview.Theycontainsubjectmatterthatisclinically
relatedandwillreinforcethelecturecontentineachslideseries.Thequestionsforthecasefollowtheintroductory
caseslide,andthediscussionforthecaseisintheslidenotes.Irecommendnotlookingfortheanswerinthe
discussionsectionuntilyouhaveattemptedtoanswerthequestiononyourown.Goodluck,andIwillseeyouin
thenexttopic.

Slide30:Questions

 Slide31:References