Approach to Patients with Motor & Sensory Disorders

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Clinical Method of Approach to Neurologic Patients

1. The signs and symptoms are secured by history and PE.

2.

The symptoms and physical signs considered relevant to the problem at hand are interpreted in terms of physiology and anatomy.
These analyses permit the AMD to localize the disease process, name the parts involved (Topographic or anatomic diagnosis). Look for characteristic clustering of symptom and signs, constituting a syndrome of anatomic, physiologic, or temporal type. Syndromic Diagnosis
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

3.

Clinical Method of Approach to Neurologic Patients

4. From the anatomic diagnosis and other medical data particularly the mode and speed of onset, evolution, and course of the illness, the involvement of nonneurologic organ systems, the relevant past and family histories, and the laboratory findings you deduce the pathologic diagnosis and when the mechanism and causation can be determined, the etiologic diagnosis. 5. Lastly, assess the degree of disability whether temporary or permanent functional diagnosis.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Answer the following Questions:

1. Is there a neurologic problem? 2. Where is the lesion?
1. Level 2. Localization 3. Lateralization

3. What is your Diagnosis?

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Points to Consider

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Test of Motor Function

Observation the speed and strength of movements and of muscle bulk, tone, and coordination are more informative than the state of tendon reflexes. Watch the patient maintain the arms outstretched in prone and supine position. Estimates of stregth of leg muscles in a supine pt is often inaccurate, you may require him to stand if possible.

Watch for drift, maintenance of outstretched arms or leg against gravity.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Testing for Sensory Function

Most difficult part of the neurologic exam. Usually reserved for the end of the examination. Explain test briefly, too much details may confuse the patient or may make him more vigilant and result to erroneous reports. It is not necessary to examine all areas of the skin, just do a quick comparison on both sides.

Start from the affected area to the normal area.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Approach to Motor Disorders

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

CNS vs PNS

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Upper Motor Neuron Signs

Hypertonia usually marked in flexor muscles of the

arms and extensor muscles of the legs.

Clasp - knife movement Hyperactive reflexes with or without clonus.

Upward plantar response

Spasticity

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Lower Motor Neuron Signs

Hypotonia

Abolished voluntary and reflex responses

Atrophy Fibrillations and fasciculations

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Definitions
Paralysis / Plegia
Refers to abolition of function. Loss of voluntary movement due to disruption of one of the motor pathways at any point from the cerebrum to the muscle fiber.

Paresis / Palsy
Lesser degree of paralysis. Partial loss of function.
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Anatomic Considerations of the Upper Motor Neuron

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Anatomic Considerations of the Upper Motor Neuron

Corticospinal Tract

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Paralysis Due to Lesions of the UMN

The CST may be disrupted anyway along its course:
Cortex Subcortical white matter Internal capsule Brainstem Spinal cord

Level of Involvement

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Patterns of Paralysis and their Diagnosis

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Patterns
Monoplegia
Weakness or paralysis of all muscles of one arm or leg.
Should not be applied to paralysis of isolated muscle groups or groups of muscles supplied by a single nerve or motor root.

Hemiplegia
Commonest form of paralysis. Involves arms, legs, occasionally the face.
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Patterns
Paraplegia
Weakness or paralysis of both legs.

Quadriplegia
Tetraplegia Affects all 4 extremities Diplegia
Special form of quadriplegia wherein the legs are more affected.

Triplegia
Occurs most often as a transitional condition in the development or of partial recovery from quadriplegia.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Patterns
Isolated paralysis of one or more muscle groups. Nonparalytic disorders of movement.
Apraxia, ataxia, etc.

Muscular paralysis without visible changes in motor neurons, roots, or nerves. Hysterical paralysis.
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Monoplegia
Must not be interpreted from failure to move due to pain. Ataxia or sensory disturbances can be interpreted as weakness. Parkinson's can give the same error due to rigidity, bradykinesia or conditions such as arthritis or fractures.
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Monoplegia
Monoplegia without Muscular Atrophy
Often due to lesion in the cerebral cortex.
A small cortical lesion may paralyze only half a hand or just the thumb.

Ischemia is the most common cause, small tumors or abscess may have similar effect. MS or SC tumor in its early course may cause weakness of one limb. Monoplegia due to UMN disease will exhibit UMN signs. Nerve conduction studies are normal.
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Anatomic Considerations of the Upper Motor Neuron

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Monoplegia
Monoplegia with Muscular Atrophy
More frequent than the other type. Atrophy of disuse may occur. Diseases of the Motor Neuron are common causes. Crural leg Monoplegia is usually caused by trauma of the SC or tumor, myelitis, MS, progressive muscular atrophy, late radiation effects.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Hemiplegia
Most frequent Due to disruption of the CST. Stroke, tumors, infections, vascular anomalies Weber Syndrome
Contralateral hemiparesis with ipsilateral 3rd nerve involvement Midbrain infarct

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Hemiplegia
Low pontine lesions
Ipsilateral abducens or facial palsy with contralateral paresis or plegia of the arms and legs.

Medullary lesions
Affect the tongue and sometimes the pharynx and larynx on 1 side and the arms and the legs on the other side.

Crossed paralysis
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Hemiplegia
Incomplete cervical SC lesion
Brown-Sequard syndrome Ipsilateral hemiparesis sparing the face, with loss of vibratory and position senses on the ipsilateral side and contralateral loss of temperature and pain.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Paraplegia
Usually from diseases of the SC, nerve roots, the peripheral nerves.
Tumors, acute myelitis, trauma, vascular malformations in the SC, SC infarction

Peripheral neuropathies such as GBS may start with paraplegia to quadriplegia (ascending paralysis).
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Paraplegia
Supratentorial causes include:
Midline tumors e.g. meningioma of the falx cerebri Bilateral ACA infarction

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Quadriplegia
Lesion is cervical area rather than thoracic. Causes:
Fracture dislocation with SC involvement Tumors, myelitis Foramen magnum compressive lesions

Muscular dystrophies can cause paralysis of all 4 extremities associated with muscle wasting.
Werdnig-Hoffman Disease
Pediatric age group Floppy infant syndrome
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Paralysis of Isolated Muscle Groups

Indicative of peripheral nerve diseases or of the several adjacent nerve roots. The diagnosis of an individual peripheral nerve lesion is made on the basis of weakness or paralysis of a particular muscle or group of muscles and impairment or loss of sensation in the distribution of the nerve.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Hysterical Paralysis
May be diverse. Reflexes are retained with no atrophy.

Inconsistent on repeated examinations and maneuvers.

Elicit the Hoovers Sign.
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Muscular Paralysis without Visible Changes in Motor Neurons, Roots, or Nerves May be diseases due to NMJ dysfunction or intrinsic to the muscle, infectious or metabolic causes:
MG Muscular dystrophies Myotonia congenita Familial periodic paralysis Disorders of the Na, K, Ca, and Mg metabolism Tetanus, botulinum poisoning Endocrine, steroid, statin myopathies
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Approach to Sensory Disorders

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Considerations
Under normal conditions, motor and sensory FUNCTIONS ARE INDEPENDENT OF EACH OTHER. However, interruption of other sensory pathways and destruction of the parietal cortex also has profound effects on motility. To a large extent, motor functions depend on sensory inputs.

Movement is inextricably dependent on sensation.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Anatomic Considerations

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Anatomic Considerations

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Sensory Syndromes

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Sensory Changes Due to Interruption of a Single Peripheral Nerve

Sensory loss varies, depending whether the nerve involved is predominantly muscular, cutaneous or mixed. Would be localized to its dermatomal distribution if cutaneous.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Polyneuropathies
Multiple involvement of peripheral nerves. May be purely motor, sensory or mixed. It can be classified as demyelinating or axonal. Etiology:
Metabolic Endocrine Post infectious Toxic Hereditary
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Myelinopathy vs Axonopathy

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Myelinopathy
Condition in the PNS which refers to lesions primarily affecting the myelin or the myelinating Schwann cell Segmental demyelination of the nerves is a result of immune-mediated attack on PNS myelin

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Myelinopathy
Clinico-Pathologic Correlations
Acute onset, hours or days. Initial changes may occur in the lower extremities, but not always distally. Generalized weakness with mild sensory loss. Absent tendon reflexes in all extremities Marked slowing of conduction velocities. Elevated CSF protein. Rapid recovery.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Axonopathy
A metabolic abnormality initially occurs in the cell body or throughout the axon. Long and large fibers are usually first affected. Degeneration appears to advance proximally toward the nerve cell body as long as the metabolic abnormality is present.

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Schematic Diagram

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Sensory Changes Due to Involvement of Nerve Roots (Radiculopathy)

Radicular pain
Pain arising from the dorsal root or the dorsal root ganglion.

Usually causes pain to be referred along a portion of the course of the nerve or nerves formed by the affected dorsal root.
Dermatomal pattern
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Lumbar Vertebra

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

L5
S1

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Sensory Changes Due to Involvement of Sensory Ganglia (Sensory Neuronopathy, Ganglionopathy)

Widespread disease of the dorsal root ganglia produces the same sensory defects as nerve root diseases but is unique:
Proximal areas of the body also show pronounced sensory loss. (face, oral mucosa, scalp, trunk, genitalia). Propioception is lost which gives rise to ataxia. MSR are lost. Paraneoplastic syndromes, connective tissue diseases, Sjogren syndrome, toxic exposure.
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Sensory Spinal Cord Lesions

Complete SC sensory Syndrome Posterior Cord Syndrome Brown Sequard Syndrome (Hemisection of SC) Syringomyelic Syndrome (Lesion of the central gray matter)

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Hemisensory Loss Due to a Lesion of the Thalamus

Involvement of the VPL and VPM nuclei of the thalamus, usually vascular in origin, causes loss or diminution of all forms of sensation on the opposite side of the body. Syndrome of Dejerine-Roussy With partial recovery, some patients may exhibit spontaneous pain or discomfort.
Thalamic Pain Syndrome

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Sensory Loss Due to Lesions in the Parietal Lobe

Anterior parietal lobe syndrome is characterized by:
Disturbances in the discriminative sensory functions of the contralateral side without impairment of the primary modalities of sensation unless the damage is profound.
Loss of position sense and sense of movement Impaired ability to localize touch and pain stimuli (topagnosia) Widening of two-point threshold asteriognosis
Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA

Sensory Loss Due to Lesions in the Parietal Lobe

Other clinical manifestations:
Hemineglect Sensory inattention Extinction

Neurology Lecture Series DLSU College of Medicine Ramon Carlos L. Alemany, MD, FPNA