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LYNA SOERTIDEWI
YETTY RAMLI
DEPARTEMENT OF NEUROLOGY
MEDICAL FACULTY- UNIVERSITY OF INDONESIA
CIPTO MANGUNKUSUMO HOSPITAL
JAKARTA
TOPICS DISCUSSION
CENTRAL COMPONENT OF THE
MOTOR SYSTEM
PERIPHERAL COMPONENT OF THE
MOTOR SYSTEM
CLINICAL SYNDROMES DUE TO
LESIONS OF SPECIFIC
COMPONENTS OF THE NERVOUS
SYSTEM
SUBTOPICS DISCUSSION
Motor cortical Area
Corticospinal tract (Pyramidal tract)
Corticobulbar tract
Other central components of the motor system
Anterior horn cells, anterior root and plexus of
the spinal cord
The peripheral nerves and the motor end plates
in skeletal muscle
Localization of lesions in the central motor
system
Localization of lesions in the peripheral motor
system
Motor System
MOTOR LEVEL
Hemiparesis
Phys reflexes
Patho reflexes
Cranial nerve palsy
Cortical brain fc dist
Radiks
Monoparesis
Phys reflexes
No path reflexes
Sensory ~ dermatome segment
Neuromuscular junction
Muscle
Quadry/paraparesis
Phys reflexes
Path reflexes
Sensory level
Autonom disturb
Paralysis asendens
Symmetry
KPR -/-
GBS
Fluctuate, recurrent
Activity influences
Palpebra, dysphagidisphonia
Miastenia Gravis
Motor Examination
Comparable
Health part and Paralysis part
Motor Paralysis :
upper motor neuron (UMN)
lower motor neuron (LMN)
3. Muscle disease :
Wasting muscle - atrophy
Tone decrease
Phys reflex decrease or disappear
4. Neuromuscular junction :
Fatigue weakness
Normal tone or decrease
Physiology reflex normal
5. Functional weakness :
Normal tone
Phys reflex normal
No wasting muscle
Erratic muscle strength
(Fuller, 1999)
Motor Testing
Muscle bulk & appearance
Tone
Strength
Muscle Tone
Definition : muscular resistance (apart from
gravity or joint disease)
The examiner feels when manipulating a
patients resting joint
Tone alterations:
Hypertonic
Hypotonic
Definition : is a decrease resistance the examiner
feels when manipulating a patients resting joint
Increase Range Of Motion
Hypertonic
Spasticity
Initial resistance and
then yielding when Ex
quickly manipulates the
Pts resting extremity
Clasp-knife spasticity
Greater in flexors upper
extr and extensors of
the lower extr
Rigidity
Increased musc resistance
felt throughout the entire
ROM when the Ex slowly
manipulates a Pts resting
joint
Lead-pipe rigidity
Indicates extra pyramidal
lession in basal motor
circuitry esp dopaminergic
projections
Cogwheel phenomenon
often occurs with rigidity
parkinsonism
superimposed beats with
tremor
Muscle Strength
Ask Pt to extend and raise both arms in front of
Close their eyes and count to 10.
Normally their arms will remain in place. If there is upper
extremity weakness there will be a positive pronator drift,
in which the affected arm will pronate and fall.
Pronator drift is an sensitive indicator of UMN weakness.
In UMN weakness, supination is weaker than pronation in the
upper extremity, leading to a pronation of the affected arm.
This test is also excellent for verification
of internal consistency, because
if a Pt fakes the weakness,
they almost always drop their arm
without pronating it.
The patient may move the muscle against gravity but not
against resistance from the examiner.
n.musculocutaneus; C5,6
n.radialis; C6,7
Fingers flexion
m.flexor digitorum
profundus
Ask the pt to
squeeze your finger
Grasp the pt wrist
with one hands to
steady the arm
Offer 2 fingers of
your other hand for
pt to grasp
Ask pt not to let your
fingers get away
N.Medianus & N.ulnaris; C7,8,T1
N.Femoralis; L2,3,4
Pt sitting
Pt hold the legs abducted as
you try to press them
together w your hands
on the lateral sides of
Several muscle; L45S1
the knee
Then Pt try to hold the legs
adducted (squeezed together)
as you place your hand on the
medial sides of the knee
n.obturator; L2,3,4
Dorsoflexion; L4,5;
deep peroneal nerve
Muscle Trophy
Inspection
Thenar,
Hypothenar,
Interossei
Tibialis anterior
Palpation
Motoric cortex
SSEP
UMN
EMG
plexus
LMN
Periphery nerve
NMJ
muscle
Central Paresis
Peripheral
paresis
Proprioceptive muscle
reflexes
Increased
Decreased
Exteroceptive muscle
reflexes
Decreased
Decreased
Babinsky sign
Present
Absent
Muscle atrophy
Present
Muscle tone
Increased (i.e.,spasticity;
not yet present in acute
phase)
Decreased
Clinical Feature
Clinical Feature
Brachial or Lumbar
Plexus
Multiple peripheral
Nerves
Muscle
Clinical Feature
Cerebrum
Brain Stem
Clinical Feature
Clinical Feature
Corticobulbar pathway in
the brain stem (bilateral
Lesion) (e.g.lacunar state)
Clinical Feature
Para-or Quadriparesis
Face spared
Hyperreflexia, pyramidal tract sign
No sensory deficit
Only mild weakness
LMN Diseases
Disturbances in
motor neuron
radix
plexus
periphery nerves
neuromuscular junction /
motor end plate
muscle
Motor Neuron :
Polio
Amyotrophic Lateral Sclerosis (ALS)/MND
Spinal Muscular Atrophy
Kugelberg Welander sy
Werdnig Hoffman sy
Radix :
Guillain Barre Syndrome
Polyradiculitis
Polyradiculoneuritis
Trauma : total / partial radix avulsion
HNP: iritation / radix compression
Plexus : ussually caused by trauma
LMN Diseases
neuromuscular junction
motor end plate
Myasthenia Syndrome :
* Myasthenia Gravis (MG)
* Lambert-Eaton Myasthenic Syndrome
(LEMS)
muscle - Myopathies
MYASTHENIA GRAVIS -- MG
Symptom and Sign :
- characterized by asymmetric weakness
and
- fatigability of skeletal muscle that worsens on exertion and
improves at rest
- Weakness often appears first in the extraocular muscles
- The facial and pharyngeal muscles may be affected, resulting
* dysarthria
* difficulty in chewing and swallowing
* poor muscular control of the head
Diagnosis based on : characteristic history and clinical finding
EMG test
MYOPATHIC SYNDROME
Myopathies are disease of muscle
Weakness is the most common sign of myopathy
It may be local, proximal or distal; symmetric or asymmetric
It may be muscle atrophy or hypertrophy
Skeletal deformity and/or abnormal posture may be a primary
component of the disease or a consequence of weakness
Other features include acute paralysis, myoglobulinemia,
cardiac arrhythmia, and visual disturbances
Example disease : Muscular Dystrophies
It is myopathies characterized by
progressive degeneration of muscle
and are mostly hereditary
Gowers Sign
Weakness in pelvic girdle and thigh
GAIT DISTURBANCES
Description
Related Term
Site of Lesion
Possible Cause
Antalgic gait
Steppage gait
Foot-drop gait
Sciatic or peroneal
nerve, spinal root
L4/5, motor neuron
Polyneuropathy, peroneal
paresis; lesions of motor
neuron, sciatic nerve, or
L4/5 root
Wadding gait
Duchene gait,
Trendelenburg
gait, Gluteal gait
Paresis of pelvic
girdle muscles
(Duchenne) or of
gluteal abductors
(Trendelenburg)
Myopathy, osteomalacia;
lesions of the hip joint or
superior gluteal nerve;
L5 lesion
GAIT DISTURBANCES
Description
Related Term
Toe walking
Site of Lesion
Talipes equinus,
spaticity
Possible Cause
Foot deformity, cerebral
palsy, Duchene muscular
dystrophy, habit
Spastic Gait
Paraspastic gait,
Leg Circumduction,
Spastic-Ataxic Gait
Wernicke-Mann Gait
Pyramidal tract,
Extrapyramidal
motor system
(supratentorial,
infratentorial,
spinal)
Unilateral or Bilateral
central paralysis with
spasticity, Stiffman
syndrome
Ataxia of gait
Gait ataxia,
Staggering gait,
Unsteady gait,
Tabetic gait,
Reeling gait
Peripheral nerve
Posterior column
of spinal cord,
Spinocerebellar
tracts, Cerebellum,
Thalamus,
Postcentral cortex
Polyneuropathy, disease
affecting posterior
columns, tabes dorsalis
cerebellar lesion,
intoxication,PSP
GAIT DISTURBANCES
Description
Related Term
Site of Lesion
Possible Cause
Dystonic gait
Choreiform gait
Basal ganglia
Torsion dystonia,
Dopa-responsive dystonia,
Kinesiogenic paroxysmal
dystonia, Huntington
disease
Start delay
Hypokinetic rigid
gait, Gait apraxia,
Festinating gait
Psychogenic
Gait disturbance
Functional gait
disturbance
Frontal lobe,
Basal ganglia,
Extensive white
matter lesions
Mental illness,
Malingering
THANK
YOU