Motor paralysis clinical

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Motor weakness clinical approach updated 2013

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  • Commands for voluntary movement originate in cortical association areas. The movements are planned in the cortex as well as in the basal ganglia and the lateral portions of the cerebellar hemispheres, as indicated by increased electrical activity before the movement. The basal ganglia and cerebellum both funnel information to the premotor and motor cortex by way of the thalamus. Motor commands from the motor cortex are relayed in large part via the corticospinal tracts to the spinal cord and the corresponding corticobulbar tracts to motor neurons in the brain stem. However, collaterals from these pathways and a few direct connections from the motor cortex end on brain stem nuclei, which also project to motor neurons in the brain stem and spinal cord. These pathways can also mediate voluntary movement. Movement sets up alterations in sensory input from the special senses and from muscles, tendons, joints, and the skin. This feedback information, which adjusts and smoothes movement, is relayed directly to the motor cortex and to the spinocerebellum. The spinocerebellum projects in turn to the brain stem. The main brain stem pathways that are concerned with posture and coordination are the rubrospinal, reticulospinal, tectospinal, and vestibulospinal tracts and corresponding projections to motor neurons in the brain stem. Ganong 21st
  • Motor paralysis clinical

    1. 1. MOTOR PARALYSIS: CLINICAL APPROACH Dr PS Deb MD, DM Director Neurology GNRC Hospitals Guwahati Assam, India
    2. 2. ORGANIZATION OF MOTOR NERVOUS SYSTEM
    3. 3. 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
    4. 4. MOTOR CORTEX AFFERENT 1. Adjacent cortex 1. 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).
    5. 5. CONVERGENCE OF MOTOR CONTROL ON THE ANTERIOR MOTOR NEURON
    6. 6. EXTRAPYRAMIDAL SYSTEM
    7. 7. 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
    8. 8. CONTROL OF VOLUNTARY MOVEMENT Idea Association cortex Premotor + Motor cortex Basal Ganglia Lateral cerebellum Movement Intermediate Cerebellum ExecutionPlanning
    9. 9. 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
    10. 10. Dominant supramarginal gyrus Premotor cortex Motor cortex Arcuate fiber Premotor cortex Corpus callosum Motor cortex 1 2 3 APRAXIA LESIONS 1. Bilateral Apraxia ideomotor 2. Left apraxia (right hemiplegia) 3. Left Apraxia sympathetic
    11. 11. 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 parietal 4. Buccofacial – Broca’s 5. Gait – Parasagiatal premotor 6. Limb kinetic – movement grossly resemble intended gesture but is awkward (left premotor)
    12. 12. PYRAMIDAL LESION: UMN - CLINICAL 1. Weakness 1. Distribution: Brodbant’s law 2. Recovery pattern 3. Residual weakness 2. Synkinetic movement: Mirror movement 3. Tone changes: 1. Distribution 2. Character 4. Reflex: 1. Deep 2. Superficial 5. Other: Electrical stimulation
    13. 13. MOTOR CORTEX AND CORONA RADIATA Cortex (Area 4)  Contralateral Hemiplegia  Motor seizures  Aphasia (44)  Associated:  Apraxia  Agnosia  Cortical anesthesia  Hemianopia
    14. 14. MOTOR CORTEX AND CORONA RADIATA Corona Radiata  Contralateral hemiplegia or monoplegia  No apraxia, agnosia, aphasia and seizure,
    15. 15. INTERNAL CAPSULE Contralateral Dense Hemiplegia, Genu: Face & Upper limb, Posterior Limb: Lower Limb
    16. 16. 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
    17. 17. MID - BRAIN  Webers Syndrome: Contralateral Hemiplegia , Ipsi lateral 3rd Nerve Palsy  Benedict's Syndrome: Contralateral Hemiplegia , Ipsilateral Rubral Tremor, ipsi Lateral 3rd Nerve Palsy
    18. 18. 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
    19. 19. MEDULLA Median Medullary Syndrome : Contralateral Hemiplegia, Posterior Column Ipsilateral 12th Nerve Palsy
    20. 20. SPINAL CORD: EXTRINSIC  Radicular involvement  Asymetric, progression in inverted U pattern  Ipsi Lateral Hemiplegia,  contralateral spinothalamic lesion  Ipsilateral posterior column sensory loss
    21. 21. SPINAL CORD: INTRINSIC  Dissociated anesthesia  Jacket Anesthesia  Long tract sign  Sacral sparing  Ant. Horn cell involvement  Symmetrical/ Asymmetrical  Bladder involvement
    22. 22. SPINAL CORD: BROWN SEQUARD SYNDROME  Ipsilateral Hemiplegia,  Contralateral Spinothalamic lesion  Ipsilateral posterior column sensory loss
    23. 23. CAUSES OF HEMIPLEGIA  Vascular  Traumatic  Neoplastic  Infection  Demyelination
    24. 24. TYPES OF HEMIPLEGIA  Ataxic hemiparesis: Lacular infarct  Crossed hemiparesis: Brain stem  Alternating hemiplegia: Migraine
    25. 25. 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
    26. 26. 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
    27. 27. 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 Noncompressive 1. Motor Neuron Disease 2. Syringomyelia 3. Freidric Ataxia 4. Familial spastic paraplegia 5. Multiple Sclerosis 6. Subacute Myelooptic Neuritis 7. Subacute Combined Degeneration 8. Pellagra 9. Tropical spastic paraplegia 10. Larthyrism
    28. 28. 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
    29. 29. COMPRESSIVE MYELOPATHY  Intradural  Meningioma  Neurofibroma  Intramedullary  Glioma  Ependymoma  AVM  Hemangioblastoma  Developmental Traction  Diastomatomyelia  Tethered Cord
    30. 30. 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
    31. 31. 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
    32. 32. MYELORADICULITIS  Infection  Tubercular (Arachnoiditis, Pott’s spine)  Pyogenic  Syphilitic  Spine  CV junction anomaly  Narrow canal  Toxic
    33. 33. 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
    34. 34. 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
    35. 35. 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
    36. 36. LMN SYNDROMES: BIBRACHIAL WEAKNESS  Ant. Horn cell  ALS  Polio  Syringomyelia  Nerve  AIDP  Porphyria  Plexus  Brachial neuritis (rare)
    37. 37. 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
    38. 38. LIMB GIRDLE SYNDROME  Peripheral nerve  Diabetic proximal  GBS  Infectious mononeucleosis  Dyphtheria  Porphyria  Carsinomatous  Oraganophosphorus (TOCP)  Neuromuscular junction  Myasthenic syndrome  Ant. Horn cell  MND  SMA
    39. 39. 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
    40. 40. 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
    41. 41. FOCAL WEAKNESS  Muscle  Congenital restricted myopathy  Peripheral nerve  Root / plexus  Ant horn cell  Cord  Cortex
    42. 42. WAISTING  Congenital  Lower motor neuron  Disuse  UMN  Bone/ joint disease  Systemic disease
    43. 43. 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
    44. 44. LOCALIZED MUSCLE MASS  Rupture muscle  Muscle hemorrhage  Muscle tumor  Myositis ossificans  Granuloma  Abscess  Fibrositis
    45. 45. QUALITATIVE CHANGES IN MUSCLE CONTRACTION  Myasthenic state  Inverse myasthenia  Contraction myodema  Myotonia  Paradoxical myotonia  Tetanus  Contracture true/ pseudo  Ankylosis  Vlkman’s ischemic contraction
    46. 46. CONTINUOUS MUSCLE FIBER ACTIVITY  Isaac Martine syndrome  Stiffman syndrome  Toxin  Strychnine  Black widow spider bite  Tetanus
    47. 47. FASCICULATION  Benign  Ant horn cell disease  Root compression  Systemic  Anticholene estaterase  Thyrotoxicosis  Electrolyte imbalance  Alkalosis
    48. 48. MYOKIMIA  Benign (leg, eyelid)  Isaac martin syndrome  Hyperthyroidism  Uremia  Tetany  Facial  MS  Brain stem tumor  Extramedulary post fossa tumor
    49. 49. CRAMP  Exersion  Dehydration and salt deplition  Pregnancy  Hypothyroidism  Denervation:  MND  Neuropathy  Toxic  Diuretic  Clofibrate  Ant choline estarase  Tetany  Continuous muscle fiber activity
    50. 50. THANKS

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