7/28/2015
Motor Syste m
Orestes E. Solis, MD, FPNA
Department of Neuroscience
L N U – College of Medicine
Objectives
• To review the anatomy of the motor system
• To be able to trace the pathways involving motor control
• To be able to demonstrate skill in examination of the motor system
• To be to demonstrate knowledge in neurologic localization involving
the motor system
• To be able to identify the manifestation of disease affecting the
components of the motor system
1
7/28/2015
Components that control motor function
• Pyramidal system (UMN or CST)
• Motor Cortex
• Direct motor pathways: CST/CNT
• Indirect descending motor pathways: *ReS, RuS, VS*
• Extra-pyramidal system
• Basal Ganglia
• Cerebellum
• Control of Eye Function
• Sensory system
2
7/28/2015
PYRAMIDAL SYSTEM
• Neurons whose fibers are contained in medullary pyramids
• Neurons
• Minority : BA 4
• 3-4% : Betz cells
• Mostly : BA 6 (Frontal), BA 1,2,3,5,7 (Parietal)
PYRAMIDAL SYSTEM
• Connections
• Internal Capsule, Basis Pedunculi, Medullary Pyramids
• Majority decussate (caudal medulla)
• Lateral Corticospinal Tract (spinal cord)
• Function:
• Facilitatory (excitatory) in total effect
3
7/28/2015
Cerebrum
Cerebrum
Cerebellum
Specific Sulci/Fissures:
Central Sulcus
Longitudinal Fissure
Sylvian/Lateral
Fissure
Transverse Fissure
http://www.bioon.com/book/biology/whole/image/1/1-8.tif.jpg http://www.dalbsoutss.eq.edu.au/Sheepbrains_Me/human_brain.gif
4
7/28/2015
Lobes of the Brain (4)
• Frontal
• Parietal
• Occipital
• Temporal
Primary Motor
Cortex/ Precentral
Gyrus
Broca’s Area
Orbitofrontal
Cortex
Olfactory Bulb
Modified from: http://www.bioon.com/book/biology/whole/image/1/1-8.tif.jpg
5
7/28/2015
Motor Cortex
Area 4 and Areas 6, 3,2,1
• Primary motor – least excitable
• Premotor – programming (sequence and modulation)
• Prefrontal – planning and initiation
• Supplementary motor
Area 8
• Frontal Eye field
Motor System
Broadmann Areas
6
7/28/2015
MOTOR PATHWAY
7
7/28/2015
Motor System
Spinal cord termination
Lamina IX
Anterior Horn cell
Motor unit
8
7/28/2015
Lower motor neuron – final common pathway of
all descending pathway
• Alpha motor neuron
• Motor unit
• Gamma motor neuron (Muscle spindle)
• Beta motor neuron (Co-contraction)
• Interneurons (Reciprocal Inhibition)
• Renshaw cells (Recurrent Inhibition)
9
7/28/2015
EXTRAPYRAMIDAL SYSTEM
• All other descending neural pathways
• Neurons
• BA 4,5,2,6, and 8
• Connections
• Internuncial neurons (Basal Ganglia)
• Neurons in brainstem
• red nucleus, vestibular nucleus, reticular nucleus
• Neurons in Cerebellum
10
7/28/2015
11
7/28/2015
Basal Ganglia Circuitry
CEREBELLUM
SOMATOTOPIC ORGANIZATION
12
7/28/2015
CEREBELLAR OUTPUTS
EXTRAPYRAMIDAL SYSTEM
• Function
• Inhibitory in total effect
• Normal
• Fluidity of movement (not coarse), normal tone and reflexes, (-) Babinski
• Damaged
• Involuntary movements, increased tone (rigidity and/or spasticity), normal
reflexes or hyperreflexia, (-) Babinski
13
7/28/2015
Clinical Manifestations
FOCAL NEUROLOGIC DEFICITS
A. CEREBRAL DYSFUNCTION
• Seizure
• Language disorder – aphasia
• Organic mental, behavioral & personality
changes
• Contralateral
• Hemiparesis with Babinski & cranial nerve deficits
• Hemisensory deficits
• Homonymous hemianopsia/quadrantanopsia
Clinical Manifestations
FOCAL NEUROLOGIC DEFICITS
B. BRAINSTEM DYSFUNCTION
• “Crossed motor/sensory syndrome”
• Ipsilateral cranial nerve deficits
• Contralateral hemiparesis with Babinski
• Ipsilateral limb ataxia
• Internuclear opthalmoplegia – median
longitudinal fasciculus syndrome
14
7/28/2015
WEBER’S
SYNDROME
FOVILLE’S
SYNDROME
Manifestation of Motor System Disease
UMN LMN
Weakness or paralysis of Weakness or paralysis
voluntary movements (segmental)
(coordinated and skilled
movements)
Hypertonia or spasticity Hypotonia or flaccidity
Hyperreflexia with or without Hyporeflexia or areflexia
clonus
Atrophy (Chronic/ Disuse) Atrophy
Abnormal plantar response Fasciculation
15
7/28/2015
BABINSKI SIGN
NEUROLOGICAL EXAMINATION
• Muscle Tone
• Righting reflex
• contraction of anti-spasticity muscles relative to position) to maintain (erect) posture
• Modified by extrapyramidal system
• Stretch reflex
• elicited by postural change
16
7/28/2015
NEUROLOGICAL EXAMINATION
• Muscle Tone
• Tone
• Dependent on position, muscle relaxation, and location of muscles
• Tone determination
• Personal experience
• Difficult to quantify
• Arbitrary grading : 0 = no tone (flaccid)
+1 to +2 = normal
+3 = hypertonus
DISTURBANCES OF MUSCLE TONE
• SPASTICITY
• Loss of suprasegmental influence
• Increased muscle tone
• UMN lesion : increase tone in flexors of upper extremities, extensors of lower
extremities
• Clasp Knife : rapid passive movement, increase resistance then sudden
relaxation (inhibition from tendon receptors – Golgi)
• Tendon reflexes = hyperactive
17
7/28/2015
DISTURBANCES OF MUSCLE TONE
• RIGIDITY
• COGWHEEL :
• rhythmic resistance to passive movement
• Alternate contraction
• LEAD – PIPE :
• Continuous increased tone
DISTURBANCES OF MUSCLE TONE
• HYPOTONICITY
• Muscle soft and flabby (less normal resistance)
• Damaged proprioception or motor innervation of muscle
18
7/28/2015
EXAMINATION OF MUSCLE TONE
• OBSERVATION
• Patient standing / sitting straight
• NORMAL : slight forearm flexion
• Exaggerated: spasticity and rigidity
• Lost : hypotonia
• Overextension
• Increased flexion
• Flailing when body shaken
EXAMINATION OF MUSCLE TONE
• OBSERVATION
• Palpate muscles
• Normal : firm
• Tensed
• Flabby
• Patient walking
• Normal : regular arm swing
• Hypertonic
• Hypotonic
19
7/28/2015
EXAMINATION OF MUSCLE TONE
• RESISTANCE TO PASSIVE MOVEMENT
• Patient relaxed (go loose, as if asleep, go floppy)
• Physician moves muscles at joints freely
• Normal : mild, even resistance to movement
• Test from head to ankle
EXAMINATION OF MUSCLE TONE
• PENDULOUSNESS
• Swinging extremity freely
• Normal : pendulousness diminishes steadily
• Observe : duration, regularity of pattern of swinging
• Hypotonia : increased pendulousness
20
7/28/2015
EXAMINATION OF MUSCLE TONE
• POSTURAL FIXATION
• Maintaining desired posture without need for correcting movement
• Impaired :
• disordered muscle tone weakness
• loss of joint position sense
• vestibular dysfunction
EXAMINATION OF MUSCLE TONE
• POSTURAL FIXATION
• Deviation Tests
• Arms extended, fingers spread, wrist extended, eyes closed
• The weak (hypotonic) arm tends to drop
• When suddenly tapped (arm), it oscillates several times (Rebound
Phenomenon)
• In disorders of cerebellar control circuits
• In vestibular dysfunction, slow rotation to one side
• The fist also shows :
• abnormal movements : chorea, athetosis, myoclonus, asterexis, and
tremors
21
7/28/2015
Muscle Strength
• Complaints: “tiredness, fatigue, weakness, ‘ngalay’, ‘mahina’, ‘walang
lakas’
• General survey:
- stand straight; feet together - sit straight
- walk on toes/heels - extend arms fully
- squat one leg up - elevate both legs
Individual Muscle Testing:
Grading of Manual Muscle Testing: 0-5
Grading
0 No contraction
1 Evidence of contraction, no gross movement
2 Side to side but cannot move against gravity
3 Moves against gravity but not against resistance
4 Moves against slight resistance
5 Moves against maximal resistance
22
7/28/2015
Neck and Trunk
• Examined in groups
1. Flexors of the Neck
(Cervical Nerve, C1-C6)
Test
Flexion of neck (hand
on chest) against
resistance applied to
forehead
Neck and Trunk
• Examined in groups
2. Extensor of Neck
(Cervical Nerve, C1-T1)
Test
Extension of neck
against resistance
applied to occiput
23
7/28/2015
Trapezius
(Spinal Accessory Nerve)
Action
Shrug shoulders
Test
Shrug shoulders against
resistance
TRAPEZIUS
Biceps, Brachioradialis (Musculocutaneous Nerve,
Brachial Plexus Lateral Cord C5-C6)
Action
Biceps – flexion and
supination of forearm
Brachioradialis – flexion of
forearm and elbow
Test
flexion of forearm
against resistance,
forearm should be in
supination
24
7/28/2015
Triceps (Radial Nerve, Brachial Plexus
Posterior Cord C6, C7, C8)
Action
Extension of forearm
and elbow
Test
Flexed forearm of
varying degrees,
resists effort to flex
further
Gluteus Maximus ( Inferior Gluteal Nerve, L5,
S1-S2)
Action
Extension of thigh at hip
Test
Standing/supine – thigh
slightly raised, extension
( downward movement)
of thigh against
resistance (under the
distal part of the thigh)
25
7/28/2015
Quadriceps Femoris( Femoral Nerve, L2-L4)
Action
Extension of leg at knee
Test
Sitting/supine – lower
leg in moderate
extension, in resistance
of extension against
effort of examiner to flex
leg at knee)
Anterior Tibial Nerve ( Deep Peroneal nerve,
L4, L5, S1)
Action
Dorsiflexion and inversion
of foot
Test
Dorsiflexion of foot against
resistance applied to
dorsum of foot
downwards
26
7/28/2015
Gastrocnemius, Soleus ( Tibial Nerve L5, S1-2)
Action
Plantar flexion of foot
Test
knee extended, test both
muscle
knee flexed – test soleus
muscle, plantar
flexion of foot against
resistance
COORDINATION
LIMB POSITION
MUSCLE Voluntary
CONTRACTION cerebellum
activity
SENSORY Proprioceptive Via: Brachium pontis
INFORMATION endings • Spinocerebellar
• Muscle spindles Pathway
Vestibular, •Tendons and joints
touch, • Inferior / Superior
visual, Cerebellar
Peduncle
auditory
27
7/28/2015
EXAMINATION OF COORDINATION
• Finger – to – Nose Test (FTNT)
• Patient’s index finger touching his nose, then touch tip of
examiner’s index finger, continuously while examiner
changes his fingers position
• Abnormality :
• Dysmetria
INTENTION TREMOR
28
7/28/2015
EXAMINATION OF COORDINATION
• Alternate Pronation – Supination Test (APST)
• Patient seated, he taps his lap alternating with palm and
dorsum of hand
• Abnormality :
• Dysdiadochokinesia
EXAMINATION OF COORDINATION
• Heel – Knee – Shin Test (HKST)
• Patient seated, he raises his lower leg, touches his knee
with his heel, then slides it down smoothly along his shin
• Abnormality :
• Dysmetria
29
7/28/2015
EXAMINATION OF COORDINATION
• Rebound Phenomenon : check and balance
• Arms extended parallel, examiner taps briskly one arm,
oscillating briskly, then checks original position
• Abnormality :
• extended oscillation
EXAMINATION OF COORDINATION
• Posture
• Standing and sitting straight
• Abnormality :
• swaying, titubation, inability to maintain posture
30
7/28/2015
EXAMINATION OF COORDINATION
• Tandem gait
• Walk a straight line, one foot touching the other foot
• Abnormality :
• incoordination
EXAMINATION OF COORDINATION
• Posture : check and balance
• Patient standing, examiner behind, pulling patient’s
shoulder backward
• Normal :
• One leg moves back to maintain erect position
• Abnormality :
• Undue fall
31
7/28/2015
CEREBELLAR HEMISPHERE LESION
IPSILATERAL LIMB ATAXIA
Clinical Manifestations of Cerebellar Disease
A. Hypotonia
B. Ataxia
• Dysmetria
• Intention tremor
• Decomposition of movement
• Dysdiadochokinesia
• Rebound
• Speech disturbance – scanning dysarthria
• Nystagmus
32
7/28/2015
Clinical Manifestations of Basal Ganglia Disease
A. Dyskinesias
• Hypokinesia
• Hyperkinesia
• Akinesia
B. Parkinsonism
• Rest tremor
• Bradykinesia
• Rigidity
Thank you for
listening…
33
