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

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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

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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

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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

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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

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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

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MOTOR PATHWAY

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Motor System
Spinal cord termination
Lamina IX
Anterior Horn cell
Motor unit

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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)

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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

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Basal Ganglia Circuitry

CEREBELLUM
SOMATOTOPIC ORGANIZATION

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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Clinical Manifestations of Basal Ganglia Disease

A. Dyskinesias
• Hypokinesia
• Hyperkinesia
• Akinesia
B. Parkinsonism
• Rest tremor
• Bradykinesia
• Rigidity

Thank you for

listening…

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