motor paralysis clinical
DESCRIPTION
Motor weakness clinical approach updated 2013TRANSCRIPT
MOTOR PARALYSIS: CLINICAL APPROACH
Dr PS Deb MD, DM
Director Neurology
GNRC Hospitals Guwahati
Assam, India
ORGANIZATION OF MOTOR NERVOUS SYSTEM
MOTOR CORTEX
Cell types : Betz cell 35000 Origin of pyramidal tract in monkey – Russel
Demayer Frontal lobe - Area 4 31%, Area 6 29%, Parietal lobe 40% No of pyramidal fibers at medulla 10,00,000
MOTOR CORTEX AFFERENT
1. Adjacent cortex1. the somatosensory areas of the
parietal cortex,
2. theadjacent areas of the frontal cortex anterior to the motor cortex, and
3. the visual and auditory cortices.
2. Opposite cerebral hemisphere.
3. Somatosensory fibers directly from the ventrobasal complex of the thalamus.
4. Tracts from the ventrolateral and ventroanterior nuclei of the thalamus, which in turn receive signals from the cerebellum and basal ganglia
5. Fibers from the intralaminar nuclei of the thalamus (RAS).
CONVERGENCE OF MOTOR CONTROL ON THE ANTERIOR MOTOR NEURON
EXTRAPYRAMIDAL SYSTEM
SUMMARY Primary Motor Cortex:
Codes force and direction of movement Spinal motor neuron are directly under control for
precise movement. Dorsal Premotor Cortex
Movement related neuron encodes sensorimotor transformation for visual and sensory cue
Fire before movement Ventral Premotor Cortex
Encodes learned motor act fire before movement
All cortical neurons are adaptable and plastic
CONTROL OF VOLUNTARY MOVEMENT
IdeaAssociation cortex
Premotor + Motor cortex
Basal Ganglia
Lateral cerebellum
Movement
Intermediate
Cerebellum
ExecutionPlanning
APRAXIA
Loss of ability to execute learned sequence of movement on command in absence of motor, sensory, cerebellar or extrapyramidal derangement in conscious cooperative patient. (Lipmann 1900)
Loss of memory of sequence of learned act. Common disorder but missed
Usually present in acute lesion and disappear rapidly when patient improve
Usually associated with weakness and aphasia If not tested patient only use object but cannot
pantomime
Dominant supramarginal
gyrus
Premotor cortex
Motor cortex
Arcuate fiber
Premotor cortex
Corpus callosum
Motor cortex
1
2
3
APRAXIA LESIONS
1. Bilateral Apraxia ideomotor2. Left apraxia (right hemiplegia)3. Left Apraxia sympathetic
APRAXIA TYPES
1. Ideational – unable to do sequential task, can do individual task (left parietal) light a match
2. Ideomotor – unable to do even individual task (left premotor)
3. Dressing + Construction – Right parietal4. Buccofacial – Broca’s5. Gait – Parasagiatal premotor6. Limb kinetic – movement grossly resemble
intended gesture but is awkward (left premotor)
PYRAMIDAL LESION: UMN - CLINICAL
1. Weakness1. Distribution: Brodbant’s law2. Recovery pattern3. Residual weakness
2. Synkinetic movement: Mirror movement3. Tone changes:
1. Distribution2. Character
4. Reflex:1. Deep2. Superficial
5. Other: Electrical stimulation
MOTOR CORTEX AND CORONA RADIATA
Cortex (Area 4) Contralateral
Hemiplegia Motor seizures Aphasia (44) Associated:
Apraxia Agnosia Cortical
anesthesia Hemianopia
MOTOR CORTEX AND CORONA RADIATA
Corona Radiata Contralateral
hemiplegia or monoplegia
No apraxia, agnosia, aphasia and seizure,
INTERNAL CAPSULE
Contralateral Dense
Hemiplegia,
Genu: Face & Upper
limb,
Posterior Limb:
Lower Limb
BRAIN STEM
Extrinsic lesion Cranial nerve first Hearing loss
common Long tract sign late
Intrinsic lesion Long tract early
Corticospinal – ant lateral
Spinothalamic – Post lateral
Post column – Medial Cerebellar – Medial
Horner’s , INO, gaze palsy
Crossed Hemiplegia Ataxic Hemiparesis Cranial nerves
MID - BRAIN
Webers Syndrome: Contralateral Hemiplegia , Ipsi lateral 3rd Nerve Palsy
Benedict's Syndrome: Contralateral Hemiplegia , Ipsilateral Rubral Tremor, ipsi Lateral 3rd Nerve Palsy
PONS Millard Gubler
Syndrome Contralateral, Hemiplegia, 6th & 7th Nerve Palsy
Foville Syndrome : Contralateral hemiplegia 6th & 7th Nerve Palsy , Ipsi Lateral Gaze Palsy
Ataxic hemiparesis Clumsy hand
syndrome
MEDULLA
Median Medullary Syndrome : Contralateral Hemiplegia, Posterior Column Ipsilateral 12th Nerve Palsy
SPINAL CORD: EXTRINSIC
Radicular involvement
Asymetric, progression in
inverted U pattern
Ipsi Lateral Hemiplegia,
contralateral spinothalamic
lesion
Ipsilateral posterior column
sensory loss
SPINAL CORD: INTRINSIC
Dissociated anesthesia
Jacket Anesthesia
Long tract sign
Sacral sparing
Ant. Horn cell involvement
Symmetrical/ Asymmetrical
Bladder involvement
SPINAL CORD: BROWN SEQUARD SYNDROME
Ipsilateral
Hemiplegia,
Contralateral
Spinothalamic lesion
Ipsilateral posterior
column sensory loss
CAUSES OF HEMIPLEGIA
Vascular Traumatic Neoplastic Infection Demyelination
TYPES OF HEMIPLEGIA
Ataxic hemiparesis: Lacular infarct Crossed hemiparesis: Brain stem Alternating hemiplegia: Migraine
MONOPLEGA
Usually part of asymmetric hemiplegia, paraplegia Partial weakness Ataxia Sensory loss Pain
UMN: Vascular, Demyelination, tumor, abscess, granuloma, Cortical Subcortical Internal capsule Brain Stem Spinal Cord: Demyelination, tumor
MONOPLEGIA: LMN
Ant horn cell: Poliomyelitis ALS Syringomyelia (upper limb)
Ant. Root and Plexus Brachial and lumbosacral with sensory loss
Nerve Focal paralysis in the distribution of nerve With sensory loss
PARAPLEGIA Cerebral
Parasagital Meningioma Tuberculoma
Acute Trauma Vascular
Infarction Hematoma
Intra-medulary Extra- medulary
Infection Polio Epidural Abscess
Demyelination Transverse myelitis Gullain Barre’ Syndrome
Chronic Spastic
Noncompressive1. Motor Neuron Disease2. Syringomyelia3. Freidric Ataxia4. Familial spastic
paraplegia5. Multiple Sclerosis6. Subacute Myelooptic
Neuritis7. Subacute Combined
Degeneration8. Pellagra9. Tropical spastic
paraplegia10. Larthyrism
COMPRESSIVE MYELOPATHIES
Extradural Bone
Neoplastic Secondries Osteosarcoma
Infection Tuberculosis Pyogenic
Disc Prolapse Stenosis Anomalies
Meningies Inflammation
Arachnoiditis Tubercular Syphilitic Toxic
Abscess AIDS
Tumor Dermoid Epidermoid Lipoma
COMPRESSIVE MYELOPATHY
IntraduralMeningiomaNeurofibroma
IntramedullaryGliomaEpendymomaAVMHemangioblastoma
Developmental TractionDiastomatomyeliaTethered Cord
CLINICAL SYNDROMES
MON: Myelooptic Neuritis MR : Myeloradiculopathy MN : Myeloneuropathy SA : Spastic ataxic DS : Dissociated Sensory SAM : Spastic, Amyotrophic PS : Pure Spastic TM : Transverse Myelopathy PP : Painful paraplegia Qudriplegia, Parplegia, Cruisiate hemiplegia
MYELO-OPTIC NEURITIS
Demyelinating Multiple sclerosis Devic’s disease
Nutritional Subacute combined degeneration Pellagra Tropical spastic paraplegia
Toxic Lathyrism SMON
Hereditary Familial spastic paraplegia with optic atrophy
MYELORADICULITIS
Infection Tubercular (Arachnoiditis, Pott’s spine) Pyogenic Syphilitic
Spine CV junction anomaly Narrow canal
Toxic
PARPLEGIAS
Flaccid Parplegias Ant. Horn Cell Dis. Cauda equina Poly rediculitis Polyneuropathis Myasthenia Muscular Dystrophy
Dissociative Paralysis Atypical
presentation Hoover’s Sign Babinski’s combined
leg flexion test
LOWER MOTOR NEURON WEAKNESS Anatomy
Motor neuron Roots Plexus Nerve Muscle
Physology Movement
Agonist: Prime movers Antagonist Synergist: Prevent other
movement of primemovers Fixators
Speed Fast: Phasic, ballistic Slow: Tonic, ramp movement
Clinical pattern Weakness: Pattern,
distribution Tone Wasting: 80% in
two months Fasciculation Fibrillation Loss of reflex No response to
electrical stimulation
LOCALIZATION OF LMN LESIONS
Ant. Horn Cells Atrophy Fasciculation Proximal, distal,
asymmetrical All muscles of the
same segment not affected
Patchy involvement of muscles
Roots , Plexus Proximal Asymmetrical All muscles of the same root
affected Atrophy Fasciculation Areflexia
Nerves Distal Sensory loss Arflexia Anatomical distribution
Muscles Proximal, distal rare Symmetrical Retained reflexes
LMN SYNDROMES: BIBRACHIAL WEAKNESS
Ant. Horn cell ALS Polio Syringomyelia
Nerve AIDP Porphyria
Plexus Brachial neuritis (rare)
LIMB GIRDLE SYNDROME: MUSCLES Dystrophies
Duchene Becker Limb Girdle
Congenital Central core Nemalin rod Myo-tubular Fiber type disproportion
Inflammatory Poliomyelitis Dermatomyositis Collagen Vascular Sarcoidosis
Endocrine Hyperthyroidism Hyperparathyroidism Cushing’s Syndrome Acromegaly Primary
Aldoesteronism Metabolic/toxic
Acid Maltase deficiency
Periodic paralysis Carnitine deficiency Alcohol myopathy
LIMB GIRDLE SYNDROME
Peripheral nerve Diabetic proximal GBS Infectious
mononeucleosis Dyphtheria Porphyria Carsinomatous Oraganophosphorus
(TOCP)
Neuromuscular junction Myasthenic
syndrome Ant. Horn cell
MND SMA
DISTAL WEAKNESS
Muscles Myotonic dystrophy Scapuloparoneal Distal myopathy
Nerve Heriditary
Paroneal muscular atrophy
Hypertrophic polyneuropathy
Refsum disease
Toxic/Metabolic Lead Dyphtheria Porphyria
Demyelinating CIDP
Root/plexus/nerve Thoracic outlet Cauda/ conus
Ant horn cell SMA distal MND Syrings Polio
ACUTE/SUBACUTE TOTAL PARALYSIS
Muscle Ac. Polio Periodic paralysis Rhabdomyositis Paroxysmal
myoglobinuria Neuromuscular Jun.
Myasthenic syndrome Botulism Organophosphorus Succinyl choline
deficiency
Peripheral nerve AIDP Diphtheria Tick paralysis Shell fish poisoning Hypermagnicemia Porphyria
Ant. Horn cell Polio Jap B
FOCAL WEAKNESS
Muscle Congenital restricted myopathy
Peripheral nerve Root / plexus Ant horn cell Cord Cortex
WAISTING
Congenital Lower motor neuron Disuse
UMN Bone/ joint disease Systemic disease
HYPERTROPHY OF MUSCLE
Duchene’ dystrophy Becker’ dystrophy Limb girdle dystrophy Myotonia congenita Hypothyroidism De Lange’s Syndrome (hypertrophy, athetosis,
MR) Cysticercosis Malignant hyperpyrexia Hypertrophia musculorum vera Ch. Radiculopathy Kocher Derie Samelainge syndrome:
Hypothyroidsm and hypertrophied muscle
LOCALIZED MUSCLE MASS
Rupture muscle Muscle hemorrhage Muscle tumor Myositis ossificans Granuloma Abscess Fibrositis
QUALITATIVE CHANGES IN MUSCLE CONTRACTION
Myasthenic state Inverse myasthenia Contraction myodema Myotonia Paradoxical myotonia Tetanus Contracture true/ pseudo Ankylosis Vlkman’s ischemic contraction
CONTINUOUS MUSCLE FIBER ACTIVITY
Isaac Martine syndrome Stiffman syndrome Toxin
Strychnine Black widow spider bite Tetanus
FASCICULATION
Benign Ant horn cell disease Root compression Systemic
Anticholene estaterase Thyrotoxicosis Electrolyte imbalance Alkalosis
MYOKIMIA
Benign (leg, eyelid) Isaac martin syndrome Hyperthyroidism Uremia Tetany Facial
MS Brain stem tumor Extramedulary post fossa tumor
CRAMP
Exersion Dehydration and salt deplition Pregnancy Hypothyroidism Denervation:
MND Neuropathy
Toxic Diuretic Clofibrate Ant choline estarase
Tetany Continuous muscle fiber activity
THANKS