DISORDERS OF MOTOR SYSTEM

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

Etiology Motor Disturbances

1). Vascular -- Stroke
2). Infection
3).Tumor
4).Trauma
5). Genetic

Motor System
MOTOR LEVEL

Upper Motor Neuron / UMN (corticospinal

system cortex to sinap in cornu
anterior)
Lower Motor Neuron / LMN ( cornu
anterior in medulla spinalis and axon to
last axon in Neuro Muscular Junction)
Neuro Muscular Junction / NMJ
Muscles
HAVE TO REMEMBER :
Paralysis? What should you do ?
Identification paralysis type UMN, LMN, NMJ, Muscle
Why? Every symptom and sign related to the specific
anatomical location

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

Proxymal > distal

Gower sign
Duck gait
No sensory disturbances

Paralysis asendens
Symmetry
KPR -/-

GBS

Fluctuate, recurrent
Activity influences
Palpebra, dysphagidisphonia
Miastenia Gravis

Motor Examination
Comparable
Health part and Paralysis part

Patient Position, Standing, Gait,

Lie down, Involuntary movement
Muscle Bulk & Appearance
Muscle Tone
Motor Strength
Physiology and Pathology Reflexes

Motor Paralysis :
upper motor neuron (UMN)
lower motor neuron (LMN)

5 pattern of motor paralysis

1. upper motor neuron (UMN), clinical

features :
Tone
Physiology reflex
Pyramidal tract paralysis (extensor in
the arms and flexor in the leg, and also
patho
logical reflex positive))
2. lower motor neuron (LMN), clinical
features :
Wasting muscle -- atrophy
Fasiculation
Tone

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 bulk &

appearance
Subjective
Quite dependent on the age,
sex and the activity / fitness
level of the individual
Look for
Palpation underlying mass, pain
Asimmetry particular pattern?
Involuntary activity tremor,
twitching

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.

There is a 0 to 5 rating scale for muscle strength:

0

detected No muscle contraction is

A trace contraction is noted in the muscle by palpating the

muscle while the patient attempts to contract it.

The patient is able to actively move the muscle when

gravity is eliminated.

The patient may move the muscle against gravity but not
against resistance from the examiner.

The patient may move the muscle group against some

resistance from the examiner.

The patient moves the muscle group and overcomes the

resistance of the examiner. This is normal muscle
strength.

+ and - can be added to these values, providing further gradations of

strength. Thus, a patient who can overcome moderate but not full
resistance might be graded 4+ or 5- .

Testing the strength of

upper arm muscles
Elbow flexors - biceps
Pt tightly flexes the
forearm
Brace one hand
against the Pts
shoulder
With the other hand
grasp the pts wrist
and attempt
straighten the Pts
forearm

n.musculocutaneus; C5,6

Testing the strength of

Upper arm muscles
Elbow extensors
Triceps muscle
antigravity test with
extension elbow
strength >> it means
false negative
Pts elbow flexed
Grasp the wrist oppose
extension of the forearm
by the Pt.

n.radialis; C6,7

Testing the strength of

Forearms muscles
Wrist flexors
Very strong antigravity
muscles.
Pt makes a fits
Holds the wrist flexed
against your efforts to
extend it
By hooking your fingers
around Pts fist and flexing
your own wrist with your
other hand

n.Medianus & n.ulnaris; C7,8,T1

Testing the strength of

Forearms muscles
Wrist extensors
Rest the Pts forearm on
his thigh or a table top for
support
The Pt then holds the wrist
cocked-up (dorsoflexed) as
you try to press it down
with the butt of your palm
on the Pts knuckles
n.radialis; C6,7

Testing the strength of

Fingers muscles
Carefully inspect and
palpate the thenar &
hypothenar eminences
for size & asimetry
Look for atrophy of
interosseus muscles
Most old people show
obvious interosseus
atrophy

Testing the strength of

Fingers muscles
Abduction-adduction of the
fingers
1st dorsal interosseus
muscle
Moves the index finger away
from middle finger and towards
the thumb
Press the terminal phalanx of
your right index finger
alongside the resisting terminal
phalanx of the Pts right index
finger, matching muscle to
muscle

Testing the strength of

Fingers muscles
Abduction-adduction of the fingers

Ulnar nerve; C8T1

Ulnar nerve; C8T1

Testing the strength of

Fingers muscles
Finger extension
Pt holds out the hand with palm down, finger
hyperextended
Turn your hand over so that the dorsum of your
fingernail presses against the dorsum of the Pts

Extensor Digitorum C7 Radial (Posterior Interossious)

Testing the strength of

Fingers muscles

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

Testing the strength of

Hip Girdle
Hip flexionThe
m.iliopsoas
With the Pt sitting
Ask Pt to lift a knee off of
thetanle surface and to hold
the thigh in a flexed position
With the butt of your palm,
try to push the knee back
down
on-antigravity muscular
relatively weak advantage
by flexed position

N.Femoralis; L2,3,4

Testing the strength of

The
Hip
Girdle
Thigh abduction &
adduction

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

Testing the strength of

The Hip Girdle
Hip extension
m.gluteus maximus
Pt prone position
Pt lift the knee from the
table surface and hold it
up
Place your hand on the
popliteal space and try
to press the knee back
down
n.Gluteal inferior; L5S1

Testing the strength of

The Thigh Muscle
Knee extensor m.quadriceps
Antigravity muscle very
strong
Pt prone
Pt try to the heel to the
buttock
Ex grasp the Pts ankle
and oppose extention
Knee flexors harmstrings
Pt hold the knee at >90o
Ex try to straighten it by
grasping Pts ankle

Testing the strength of

The Ankle and Toe movements
Have the Pt dorsiflex, invert, and evert the feet
Pt holds the toes flexed or extended as
Ex attempts to press them back to neutral position
Plantar flexion Antigravity muscle paling kuat
big toe flexion is stronger than extension

Plantarflexion; n.sciatic; S1S2;

m.gastrocnemius & m.soleus

Dorsoflexion; L4,5;
deep peroneal nerve

Muscle Trophy
Inspection
Thenar,
Hypothenar,
Interossei
Tibialis anterior
Palpation

Motoric cortex

SSEP

UMN

Cornu anterior (motorneuron)

radix

EMG

plexus

LMN

Periphery nerve

NMJ
muscle

Characteristics of central and peripheral paresis

Feature

Central Paresis

Peripheral
paresis

Proprioceptive muscle
reflexes

Increased

Decreased

Exteroceptive muscle
reflexes

Decreased

Decreased

Babinsky sign

Present

Absent

Muscle atrophy

Absent (or mild atrophy

of disuse)

Present

Muscle tone

Increased (i.e.,spasticity;
not yet present in acute
phase)

Decreased

Sites of lesions causing MONOPARESIS, and corresponding clinical feature

Site of Lesion

Clinical Feature

Central Nervous System

Spastic paresis (increased muscle tone,

increased reflexes)
No muscle atrophy
Possibly a purely motor deficit
(e.g., contralateral leg paresis due to ischemic
in the territory of the anterior cerebral
artery)

Anterior Horn of Spinal

Cord (Chronic Lesion)

Paresis of individual muscles with

accompanying atrophy and decreased tone
No sensory deficit
Possibly accompanied by fasciculations
Decreased proprioceptive muscle reflexes
(but maybe increased in Amyotrophic
Lateral Sclerosis)

Sites of lesions causing MONOPARESIS, and corresponding clinical feature

Site of Lesion

Clinical Feature

Brachial or Lumbar
Plexus

Mixed sensory and motor deficit

Decreased muscle tone
Muscle atrophy, decreased proprioceptive
muscle reflexes
Sensory deficit for all modalities

Multiple peripheral
Nerves

Same as in plexus lesions in a single limb

Muscle

Hardly ever a pure monoparesis; if so then

flaccid
Purely motor deficit, sometimes with muscle
atrophy

Sites of lesions causing HEMIPARESIS, and corresponding clinical feature

Site of Lesion

Clinical Feature

Cerebrum

Spastic hemiparesis, possibly also involving

facial muscles, characterized by :
* increased muscle tone
* increased reflexes
* pyramidal tract signs
* no atrophy
Usually associated with a sensory deficit
in the same site
Cranial nerve deficits ipsilateral to
hemiparesis

Brain Stem

Spastic hemiparesis, as above

Cranial nerve deficits contralateral to
hemiparesis
(Hemiparesis Alternans)

Sites of lesions causing HEMIPARESIS, and corresponding clinical feature

Site of Lesion

Clinical Feature

Upper Cervical Spinal Cord

Spastic hemiparesis, as above

Possible ipsilaleral loss of position and
vibration sense and contralateral loss of pain
and temperature sense below the level
of the lesion
(Brown- Sequard Syndrome)

Sites of lesions causing PARA-OR QUADRIPARESIS, and corresponding

clinical feature
Site of Lesion

Clinical Feature

Cerebrum (bilateral lesion)

Clinical picture of bilateral hemiparesis or

paraparesis due to a bilateral parasagittal
cortical lesion

Corticobulbar pathway in
the brain stem (bilateral
Lesion) (e.g.lacunar state)

Bilateral spasticity with only mild weakness

Spastic, small-stepped gait
Hyperreflexia, pyramidal tract sign
No sensory deficit
Usually accompanied by pseudobulbar signs
(dysarthria, hyperreflexia of the facial
musculature)

Sites of lesions causing PARA-OR QUADRIPARESIS, and corresponding

clinical feature
Site of Lesion
Corticospinal pathway in
the spinal cord (bilateral
lesions)

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

Clinical features of an isolated lesion of the anterior horn ganglion cells

Muscles Atrophy usually in 2-3 weeks
Weakness -- flaccid
Fasciculations (in chronic phase)
Intact Sensation
Decreased or Absent reflexes
But : hyperreflexia and pyramidal tract sign in Amyotrophic Lateral Sclerosis,
which involves not only the anterior horns but also the corticospinal
pathways (thus the term lateral sclerosis, as these pathways are
lateral in the spinal cord)

Guillain Barre Syndrome (GBS)

(Polyradiculopathy)
Onset is 1-4 weeks after a respiratory or gastrointestinal infection
To be associated with certain viruses
Symptoms and sign :
* acute ascending and often rapidly progressive symmetrical weakness
-- flaccid type, which usually begins in the lower limbs
* motor deficits dominate the clinical picture
* areflexia
* relatively mild sensory abnormalities (paresthesia)
* a rapid ascending weakness severe one called LANDRY type
Diagnosis from its typical clinical features
CSF studies albuminocytologic dissociation

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

Limping gait, leg

difference, limp

Foot, leg, pelvis

spinal column

Lumbarr oot lesion, bone

disease, peripheral nerve
compression

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

PD, Frontal lobe lesion,

NPH, Binswanger dis

Mental illness,
Malingering

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