MOTOR SYSTEM

Dr.Ahmed Gaber Ass. Prof of Neurology Ain Shams University

ORGANIZATION
MOTOR SYSTEM

UMNL

LMNL

PYRAMIDAL

EXT PYRAMID

CEREBELLAR

AHC

ROOTS

PLEXUS, PN

MNJ, MS

 Upper motor neurones are a descending fibre system with cells of origin in the cerebral cortex predominantly precentral gyrus that descends and after decussation to the opposite side innervates cranial nerve nuclei and the anterior horn cells.

MOTOR DYSFUNCTION
Three Patterns:
Weakness Cerebellar Ataxia Involuntary Movements.

Patterns Of Motor Weakness

Pattern Distribution Pyramidal D>P Abd>Add F>E LL E>F UL N Spasticity Hyper Lost Extensor LMN (neurogenic) No Muscle P>D MNJ NO WK Fatigue Diurnal Variation N or hypo N N N

State Tone D Reflexes Abd R Planter R

Early Atrophy Hypotonia Hypo +/N

Late Atrophy N Hypotonia Hypo N N

Expressions:
By lower motor system or unit (LMU) we mean from AHC to the muscle By Lower motor neurone (LMN) we mean from AHC till end of PN (Neurogenic Part of LMU( BY Myogenic we mean the muscle component of LMU.

LMU Weakness Patterns

LMU

AHC

Radicular

PN

MNJ

Muscle

Myotomal Distribution

Myotomal Distribution

PN Distrib (D>P)

Fatigability

Proximal

Pure M Fasciculation ++

Mixed SM Fasciculation +/-

Gloves or stalking Single N Dist

Pure M

Pure M Bilat Symm

Myotomal Distribution
MNJ

PN Ms

Root
AHC

Myotome: each segment supply certain muscles, so if segment C 5 is affected only muscle supplied by C5 is affected this called the myotomal distribution.

MYOTOMES

What are the objectives?

To identify whether UMNL/LMNL in both history and examination

MOTOR HISTORY

3 Points:
Weakness (Pyramidal,LMNL) Involuntary Movement (Extrapyramidal) Coordination (Cerebellar)

WEAKNESS
Objective: UMNL vs LMNL How: 1. Distribution (rt/lt, ul/ll, P/D, F/E, Abd/Add) 2. Tone (hypo/hyper) 3. State 4. Fasciculation

COORDINATION

Involuntary Movements

MOTOR EXAMINATION

MOTOR EXAMINATION
State Fasciculation Tone Power Coordination Reflexes Involuntary movements Gait

State
Objective: UMNL vs LMNL How:
Combined inspection and palpation (contours, chin of tibia) Measurement Comparison (sides, D/P)

INTERPRETATION
State

Atrophy

No Atrophy

Hypertrophy

LMNL

Parietal Lobe

Muscle Dystrophy

Myotonia

Fasciculation
FASCICULATION

Objective: LMNL vs UMNL How:

Tangential Inspection Tapping Muscle exhaustion
LMNL

AHCs

Root

Thyrotoxic myositis

TONE
Objectives:
Normal tone: is the equal Tone with slight resistance through whole range of movements Hypotonia Vs Hypertonia Paratonia (Gegenhalten) : patient opposes the attempts to move the limb

How:
Tests for hypertonia Tests For Hypotonia Compare Joints Test for paratonia

Special Situations:
Myotonia: Delayed ms relaxation Percussion myotonia: a dimple after tapping a muscle especially tongue and abductor pollicis brevis

How
Joint Wrist Hypertonia Passive Hypotonia Shaking

Elbow
Shoulder Ankle Knee

Passive
Passive Passive Passive

Rebound
Rebound Shaking Knee lifting, Pendular Jerk Rolling, Frogging

Hip

Passive

INTERPRETATION
Tone
Hypertonia UMNL Spasticity (P) Clasp knife Proximal Antigravity UMNL Hypotonia LMNL Area 4 Parietal Lobe cerebellar Chorea Complete Transection Paratonia Prefrontal

Rigidity) Extra P) Lead p/Cog w Distal Equal

Velocity Dependant Velocity Non Dep

POWER
Two Methods: D/P, F/E, Abd/Add: only detect pyramidal weakness vs LM lesion. Single Ms exam: applicable when a LM lesion is detected

Power Grades
5 =n 4+= Submaximal Movement against resistance 4 = Moderate Movement against resistance 4- = Slight Movement against resistance 3 = Against gravity Not resistance 2 = With gravity 1 = Flicker 0 = No movement

Single Muscle Examination

o o o o Scaleni, aplenius capitus Supraspinatus, infraspinatus, subscapularis(teres major) Serratus, Latissmus dorsi. Trapezius (upper and lower), Pectoralis Biceps, brachioradialis, triceps, supinator, pronator Wrist extension, flexion, carpi ulnaris, carpiradialis Finger long E, F, abduct, adduction Opponens pollices, adductor, flexor poll, Ext indices, abd digiti minimi. Gluteus max, Glut medius (minimus), Aductors, Ileopsoas Quadriceps, hamstrings Ant tibial, Peronei, Gastrocnemius, tibialis posterior Ext hallucis logus, ext digitorum brevis, Planter flexors

Basic Examination UL
Movement
Shoulder Abduction
Elbow Flexion Supinated Elbow Flexion Semipronated Elbow Extension Finger Extension Finger Flexion Finger Abduction Finger Adduction Thumb Abduction

Muscle
Deltoid
Biceps Brachioradialis Triceps Extensor Digitorm Flex D Sup + Prof Dorsal Interossei Palmar Interossei Abductor Poll Brevis

Nerve
Axillary n
Musculocutaneous n Radial n Radial n Post Interosseous (radial) Median+ Ulnar Ulnar Ulnar Median

Root
C5
C5>6 C6 C7) 6-8) C7>8 C8 T1 T1 T1

Further Examination UL Serratus Anterior:

Long Thoracic n C5,6,7 Push against The wall Rhomboids: N to rhomboids C4,5 Hands in waist, push elbows backwards. Subscapularis: N to subscapularis C5,6 Inward rotation of flexed arm Pectoralis Major: C5,6,7 Sternal head hand in waist Clavicular head hands pushing each other Latismus Dorsi: Elbow downward when arm hanging up

Trapezius: Shoulder Abduction more than 90 Supraspinatus: N to supraspinatus C5 First 18 deg in shoulder abduction. Infraspinatus: Suprascapular n C5,6 outward rotation of flexed arm Long Flexors of little and ring finger: Ulnar n Flexor digitorum profundus 3,4 C8 Extend distal interphalangeal joint during grip of the little and ring Finger

Basic Examination LL
Movement Hip Flexion Hip Extension Hip Abduction Hip Adduction Knee Extension Knee Flexion Foot Dorsiflexion Foot Planterflexion Iliopsoas Gluteus maximus Glut Med and Minimus Adductors Quadriceps Femoris Hamstring Tibialis Ant Gastrocnemius Muscle Nerve Lumbar plexus Inferior Gluteal n Superior Gluteal n Obturator n Femoral n Sciatic n Deep peroneal n Posterior tibial n Root L1,2 L5,S1 L5,S1 L2,3 L3,4 L5,S1 L4,5 S1

Foot Inversion
Foot Eversion Big Toe Extension Toes Extension

Tibialis posterior
Peroneus Longus & Brevis Extensor Hallucis Longus Extensor digitorum brevis

Tibial n
Superficial peroneal n Deep peroneal n Deep peroneal n

L4,5
L5,S1 L5 L5, S1

INTERPRETATION
Distribution Hemiparesis UMNL Quadreparesis Paraparesis Monoparesis

Subcortical (LL# Ul)

Capsular (UL=LL) Br Stem (CN, Cll)

INTERPRETATION
Distribution Quadreparesis Paraparesis P>D Muscle/MNJ AHC ROOTs PN AHC ROOT LMNL Hemiparesis Monoparesis

D>P UMNL SPINAL (Level) Br Stem Parasagital Bil Cerebral

INTERPRETATION
Distribution Hemiparesis P>D Myositis AHC ROOTs LMNL Monoparesis D>P UMNL Cortical Quadre/Para

PN AHC
ROOT

Single Muscle Examination Interpretation

Muscles affected can be grouped into

Myotomes

Peripheral N

Muscles (selectivity)

Root C5 C6 C7 C8 T1 L1,2

Movement Shoulder abd, Elbow flex supinated Elbow flex semipronated Elbow Ext, Finger Ext Finger Flex Small ms hand , Abd Digiti minimi Hip flexion

Reflex Biceps Supinator Triceps Finger jerk ---

L2,3
L3,4 L5

Hip Adduction
Knee Extension Ext of big toe (Ext Dig brevis, Ext Hallucis Longus)

Adductor reflex
Knee reflex (patellar) --

S1

Hip extension, Knee flexion, Planter flexion

Ankle Reflex

Nerves:
Radial: All extensors of the arm Ulnar: All intrinsic hand muscles except those by median. Median:
Lateral 2 lumbricals Opp pollicis Abd Pollicis Brevis Flexor Pollicis Brevis

Femoral: Knee extension Sciatic: Knee flexion

Post Tibial: planter flexion, inversion, small ms of foot. Common peroneal: Dorsiflexion, eversion.

Coordination
Finger to nose Finger to finger Heel to knee + eye closed Finger to doctor Finger Dysdiadocokinesia Tandem gait (eye closed) Rhombergism + rebound, nystagmus

Reflexes
DeepTendon Reflexes: o Supra spinatus, pectoral o Biceps, brachioradialis, triceps o figer jerk o Gluteal o knee (patellar) o Adductor o Gracile o Ankle Clonus: ankle, patellar, wrist
o o o o o o o o o Superficial: Ext planter adominal, cremasteric Gluteal Anal Bulbocavernosus Pathological: Hoffman Grasp, grooping suckling, snouting, palmomentalG o Gegenalten, medmachen,medgahen

Deep Tendon Reflexes Objective

MNJ

PN Ms

Root
AHC Reflex Arc

The deep tendon reflexes check the integrity of the neurogenic LMN, Afferent in deep sensory fibers and efferent in motor nerves.

Deep Tendon Reflexes

Reflex Biceps Supinator Radial Nerve Musculocutaneous Root C5>6 C6>5

Triceps
Finger Jerk Wrist Clonus Knee + clonus Adductor Ankle + Clonus

Radial
Median, Ulnar Median, Ulnar Femoral Obturator Tibial

C7
C8 C8 L3,4 L2,3 S1

Deep Tendon Reflexes Grades

0 = absent +-= present only with reinforcement 1 = depressed 2 = normal 3 = increased 4 = Clonus

INTERPRETATION of DTR
Clinical Classification: Absent reflexes Elicitable reflexes Brisk reflexes Exaggerated reflexes Polyphasic reflexes Clonus Radiating Reflexes Inverted refrlexes

What is the Normal DTR

Normality = Equality in the elicitable , exaggerated and even in the brisk state. Absent reflexes are always abnormal provided good facilitation. Polyphasic, clonus, radiating and inverted always indicate a pyramidal lesion.

Absent Deep Tendon Reflex

MNJ

PN Ms

Root
AHC Reflex Arc

Lesion in the reflex arc i.e NEUROGENIC LMNL

Exaggerated and Brisk

Exaggerated DTR Increased amplitude of the reflex Of no significance Brisk DTR: Decreased Latency of the reflex More towards a pyramidal lesion if there is inequality. The normal knee jerk is brisk reflex.

Polyphasic Deep Tendon Reflex

++++++++++++ MNJ ++++++++++++ PN Ms

Root
AHC Reflex Arc Sure Pyramidal

Increased fascilitation of the receptors of DTR (Gamma Motor neurones) --stretch reflex Increased facilitation of golgi tendon organs ---- inhibition of ms contractoin (reverse stretch reflex) --- ms relaxation Then the cycle repeat again

CLONUS
++++++++++++ MNJ ++++++++++++ PN Maintained stimulus Ms

Root
AHC Reflex Arc Sure Pyramidal

Increased fascilitation of the receptors of DTR (Gamma Motor neurones) --stretch reflex Increased facilitation of golgi tendon organs ---- inhibition of ms contractoin (reverse stretch reflex) --- ms relaxation Then the cycle repeat again

Radiating Deep Tendon Reflex

Reflex Arc ++++++++++++ Sure Pyramidal ++++++++++++

PN ++++++++++++

C5

++++++++++++ C8 Increased facilitation in the segments of Spinal cord, the reflex is not restricted to one segment but radiate down words to cause contraction in multiple myotomes

Inverted Deep Tendon Reflex

Reflex Arc ++++++++++++ Sure Pyramidal+ LMN level

++++++++++++

C5 Lesion in EFF, Aff intact

++++++++++++ C8 Increased facilitation in the segments of Spinal cord, the reflex is not restricted to one segment but radiate down words to cause contraction in multiple myotomes, however no contraction in the stimulated myotome due to efferent lesion

Superficial Reflexes
Abdominal Planter response Cremasteric Gluteal Anal Bulbocavernosus

Abdominal Reflex
Bilateral intact = normal Bilateral Lost = obese, old age, or bilateral pyramidal Unilateral lost = pyramidal or LMNL Fatigable unilateral = pyramidal

Planter Response
On the most lateral aspect Do not go medially, it will stimulate the medial planter response The medial planter response is least sensitive for pyramidal lesion and only extensor in severe pyramidal lesion.

Planter response interpretation

Normal = bilateral equal flexor Less flexor on one side = pyramidal Tendency to extension or extension = pyramidal Once extension and several flexion = pyramidal ( there is no equivocal response) No response unilateral and other flexor = pyramidal No response bilateral is not normal nor pyramidal it is equivocal.

Pathological reflexes
o o o o o o o o o Hoffman Grasp Grooping Suckling, Snouting, Palmomental Gegenalten, Medmachen, Medgahen

Examination Of The Involuntary Movements At rest position for involuntary movements at rest At Repose for postural involuntary movements During Action at

GAIT
Waddling proximal wk Foot drop (high steppage)--- PN Stamping deep S Shuffling, festinating, Toppling (propulsion)-- parkinsonian Frontal lobe gait , disequilibrium syndrome
Circumduction-hemiparesis Scissoring-- spasticity Ataxic Dyskinetic Dancing gait --- chorea Posture adjustment: Kinetic (vestibular), static (deep sensory), Corrective reflexes (Extrapyramidal system)

Thank you