Banyak pasien neuro dengan keluhan gangguan motorik, terutama kelemahan anggota badan. Tapi ternyata gangguan motorik tu nggak cuma "parese" aja.. ada banyak macemnya! (Ada yg pernah bikin stats-nya??) File ini cuma menceritakan sekelumit tentang gangguan motorik, dan si desainer ppt ini pun cuma sempet baca sedikit. Tapi dari yang sedikit ini, rasanya bikin pengen belajar lebih banyak lagi! (karena itu dikasi subtitle "Appetizer"..) Menarik banget cerita tentang jenis2 gangguan motorik ini, lokasi lesi-nya, ciri2 khususnya, n penyebabnya.. Oia, insyaAllah ppt ini akan selalu dilengkapi & diupdate sesuai referensi yg sanggup dibaca si desainer^^v (Tugas modul ini pun digarap dengan sangat senang hati, hehehehe..)

1. Gangguan Motorik
- appetizer ^^v
Ersifa fatimah
PPDS Neurologi
RSUD Dr Soetomo – Univ. Airlangga
2013

2. Referensi
Motor Disturbances Disorder of Motility
• Muscle • Motor paralysis
• LMN • Abnormal of movement &
• UMN posture due to disease of
• Basal Ganglia Basal Ganglia
• Cerebellum • Incoordination & other
disorders of Cerebellar
(Waxman, 2010) function
• Tremor, Myoclonus, Focal
dystonias, and Tics
• Disorder of Stance & Gait
(Adams & Victor’s, 2005)
ERS 2

3. The Motor System (DeJong, 2010)
Level: Motor unit, Spinal cord, Pyramidal, Extrapyramidal
Motor strength & Power
Muscle Tone
Muscle Volume & Contour
Abnormality of Movement
ERS 3

4. Knowing the structure and function
of the different levels of motor control,
the relationships
between the motor systems,
and the changes in motor activity
that occur in disease
helps in understanding
disorders of the motor system.
DeJong, 2010
ERS 4

5. Sensory and motor functions are interdependent
in the performance of volitional movement,
and it is not possible
to consider the motor system apart
from the sensory system.
Impairment of sensation may affect
all aspects of motion—
volitional, reflex, postural, tonic, and phasic.
DeJong, 2010
ERS 5

6. Corticospinal & Corticobulbar Tracts, Composition
10%
area 4 & 6
35% 55%
area 3, 1, 2
Others: frontal & parietal
The axons arising from the large
pyramidal cells in layer V (Betz's
cells) of area 4 contribute only
about 5% of the fibers of the
corticospinal tract and its
pyramidal portion.
Waxman, 2010
ERS 6

7. Disorder of Motility
The following parts of the nervous system are engaged primarily in the control of
movement and, in the course of disease, yield a number of characteristic derangements
(Adams & Victor, 2005)
Large motor neurons in the anterior horns of the Paralysis due to an interruption of
spinal cord & the motor nuclei of the brainstem  LMNs.
the axons comprise the anterior spinal roots , the Complete lesions of LMN result in a
spinal nerves & cranial nerves  innervate the loss of all movement—
skeletal muscles. voluntary, automatic, postural, and
The LMNs are the final common path by which all reflex.
neural impulses are transmitted to muscle.
Motor neurons in the frontal cortex adjacent to the Paralysis due to dysfunction of
rolandic fissure connect with the spinal motor upper motor (corticospinal)
neurons by a system of fibers known as the pyramidal neurons.
tract.
Since the motor fibers that extend from the cerebral
cortex to the spinal cord are not confined to the
pyramidal tract , they are more accurately designated
as the corticospinal tract, or UMNs,to distinguish
them from the LMNs.
ERS 7

8. Disorder of Motility (Adams & Victor, 2005)
Several brain stem nuclei that project to the spinal
cord, notably the pontine and medullary reticular
nuclei, vestibular nuclei, and red nuclei. + their
descending fibers
 posture & movement (particularly when
movement is highly automatic and repetitive)
Certain of these brain stem nuclei are influenced by
the motor or premotor regions of the cortex, e.g., via
corticoreticulospinal relays.
Two subcortical systems: the basal ganglia Involuntary movements &
(striatum, pallidum, and related structures, including abnormalities of posture due to
the substantia nigra and subthalamic nucleus) & the disease of the basal ganglia
cerebellum Abnormalities of coordination
 Play important role in the control of muscle (ataxia) due to lesions in the
tone, posture, and coordination of movement by cerebellum.
virtue of its connections with the corticospinal
system (via thalamocortical fibers) and other
descending cortical pathways
ERS 8

9. Disorder of Motility (Adams & Victor, 2005)
Several other parts of the cerebral cortex, particularly Apraxic or nonparalytic disturbances
the premotor & supplementary motor cortices. of purposive movement due to
These structures are involved in the programming involvement of association
(i.e., the sequencing and modulation) of voluntary pathways in the cerebrum
movement.
The prefrontal cortex  planning & initiation of
willed movement.
Fibers from the prefrontal cortex project to the
supplementary & premotor cortex and provide the
input to the some restrictly motor areas.
Similarly, certain parietal cortical areas (superior
parietal lobule) supply the somatic sensory
information that activates the premotor and
supplementary motor cortices and leads to directed
movement. In addition, other parts of the nervous
system concerned with tactile, visual, and auditory
sensation are connected by fiber tracts with the
motor cortex. These association pathways provide
their own sensory regulation of motor function
ERS 9

10. Levels:
• Motor Unit (LMN)
• Segmental/spinal cord
• Suprasegmental
– Various descending
systems modulate
activity in segmental
level
– Brainstem, cerebellar,
extrapyramidal,
pyramidal
– Psychomotor/ cortical
associative
Fig: The most important descending
pathways that act upon the anterior
horn cell of the spinal cord (deJong
ERS 2010) 10

11. (DeJong, 2010)
• Lat ReticuloSpinal:
– influence the musculature of
the trunk.
• Med TectoSpinal:
– reflex movement
– Trunk, neck, eyes ~ visual
stimuli
• Lat CorticoSpinal:
– Hand, finger movement
• RubroSpinal:
– Hand, finger movement
– Flexor muscle tone
– Postural
mechanism, standing/righting
reflex
• Lat VestibuloSpinal:
– Postural
mechanism, standing/righting
reflex
Mainly control trunk &
proximal extremity
ERS 11

12. DeJong, 2010
ERS 12

13. Waxman, 2010
ERS 13

14. Motor Paralysis
Terminology
Paralysis Loss of involuntary movement due to interruption of
motor pathway (cerebrum – muscle fiber)
Paresis A lesser degree of paralysis / partial loss
Plegia Severe / complete loss of motor function
Focal ~ asymmetry Ex: hemi-
Generalized ~ symmetry (although the weakness not truly general, ex.:
scapuloperoneal syndrome)
Truly generalized  bulbar is impaired
Multifocal Ex.: bilateral CTS
Non-focal Generalized, predominantly proximal, predominanly
distal
These various patterns have differential diagnostic and localizing significance.
Identification of the process causing weakness is further aided by accompanying signs,
such as reflex alterations and sensory loss. (DeJong, 2010)
ERS 14

15. Pattern of Paralysis &
Their Diagnosis
Adams & Victor, 2005
Apraxia: a state in which a clear-
minded patient with no
weakness, ataxia, or other
extrapyramidal derangement, and
no defect of the primary modes
of sensation, loses the ability to
execute highly complex and
previously learned skills and
gestures.
NMJ
ERS 15

16. Mumenthaler, 2004
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17. Bradley, 2010
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18. Bradley, 2010
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19. Mumenthaler, 2004
ERS 19

20. Bradley, 2010
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21. Bradley, 2010
ERS 21

22. ERS 22

23. Bradley, 2010
ERS 23

24. ERS 24

25. ERS 25

26. ERS Bradley, 2010
26

27. ERS 27

28. Mumenthaler, 2004
ERS 28

29. Bradley, 2010
ERS 29

30. Bradley, 2010
ERS 30

31. Proximal, Distal & General Weakness Bradley, 2010
ERS 31

32. Adams & Victor’s, 2005
ERS 32

33. Features of UMN vs LMN Weakness
(DeJong, 2005)
+ UMN LMN
Weakness Corticospinal Generalized, focal, predominantly
distribution distribution, hemi-, distal, predominantly proximal,
para-, quadri-, mono-, No preferential involvement of
faciobrachial corticopsinal innervated muscle
Sensory loss Central pattern None, stocking glove, peropheral / root
distribution distribution
Sphincter function Sometimes impaired Normal (except for cauda equina
lesion)
Pain No Sometimes
Other CNS sign Possibly No
Corticospinal distribution:
• Distal muscle
• Upper ext: esp hand; wrist, finger & elbow extnsor, supinator, external rotator,
abductor shoulder
• Lower ext: foot & toe dorsiflexor, knee flexor, hip flexor & internal rotator,
ERS 33

34. Muscle Tone (DeJong, 2010)
Hypotonia Hypertonia
Myopathy Cerebellar Spasticity Rigidity Dystonia:
disease most marked the increased tone occurs to transient or
near the more or less the same degree sustained
middle of the throughout the range of hypertonic
range of passive motion of a limb, and is conditions that
motion, more independent do not fit into
apparent with of the speed of the movement the other
fast than with categories
slow passive Lead pipe Cogwheel Paratonia:
movement smooth ratchety, jerky, increase in tone
resistance tremulous in a limb
throughout variation in the more or less
the range hypertonia, proportional to
independent due primarily the examiner's
of the rate of to attempt to
move. superimposed move it.
tremor (Gegenhalten)
ERS 35

35. Muscle Volume & Contour
(DeJong, 2010)
Atrophy Hypertrophy
Neurogenic Myogenic Disuse True Pseudo
Weakness // Weakness >> Immobilization: Physiologic apparent muscle
wasting wasting Wasting >> enlargement due to
May be Mild-moderate weakness replacement of
severe Mild-moderate diseased muscle by
Recovers quickly fat and fibrous
Anterior horn with resumption tissue
cell  of uses Ex: Duchenne
peripheral
nerve
UMN:
Usually not
followed by
atrophy
ERS 36

36. Abnormal of movement & posture
due to disease of Basal Ganglia
• Akinesia: absence of • Tremor
movement • Athetosis: slow, writhing
• Bradykinesia: abnormally movements of the
slow movement extremities & neck
• Hypokinesia: a decreased musculature
amount or amplitude of • Chorea:
movement. quick, repeated, involunta
• Dyskinesia: ry movements of distal
involuntary, abnormal extremity
movement muscle, face, tongue, ~
Waxman, 2010 corpus striatum
ERS 37

37. Extrapyramidal System
A: Basal ganglia: major Extrapyramidal motor
structures.
system:
MD, medial dorsal; VA,
ventral anterior; VL, – Corpus striatum
ventral lateral nuclei of – Subthalamic nucleus
thalamus – Substansia nigra
– Red nucleus
– Brain stem reticular
formation
– Descending spinal cord
tract other than
corticospinal tract
(Waxman, 2010)
ERS 38

38. Waxman, 2010
ERS 39

39. Adams & Victor, 2005
Waxman, 2010
ERS 40

40. Adams & Victor, 2005
ERS 41

41. Adams & Victor’s, 2005
ERS 42

42. Adams & Victor’s, 2005
ERS 43

43. Adams & Victor’s, 2005
ERS 44

44. Incoordination & other disorders of
Cerebellar function
Truncal
ataxia, drunken
gait
Ataxia, asynergy,
dysmetria, dysdia
docho-
kinesia, intention
tremor, rebound
phen.
Loss of equilibrium,
nystagmus
Adams & Victor’s, 2005 | Waxman, 2010
ERS 45

45. There is a somatotopic
organization of body parts
within the cerebellar cortex.
In addition, the cerebellum
receives collateral input from
the sensory and special
sensory systems.
Waxman, 2010
ERS 46

46. Waxman, 2010
ERS 47

47. Efferents from Cerebellum:
the dentatorubrothalamocortical pathway
Via this pathway, activity in
the dentate nucleus & other
deep cerebellar nuclei
modulates activity in the
contralateral motor cortex.
This crossed connection, to
the contralateral motor
cortex, helps to explain why
each cerebellar hemisphere
regulates coordination and
muscle tone on the
ipsilateral side of the body.
Waxman, 2010
ERS 48

48. Waxman, 2010
Terminology
Dysmetria Past-pointing phenomenon, unable to estimate
the distance involved in muscular acts  their
attempt to touch the object will overshoot the
target
Dysdiadochokinesia Inability to perform rapidly alternating movements
Rebound phenomenon Loss of interaction between agonist & antagonist
smooth muscle
ERS 49

49. Signs of Various Lesions of Human Motor system (Waxman, 2010)
* Fasciculations are spontaneous, grossly visible contractions (twitches) of entire motor units
ERS 50

50. Abnormality of movement (DeJong, 2005)
Hypokinetic Hyperkinetic
• Parkinson's disease • Regular/predictable
• Parkinsonian syndromes
– Progressive supranuclear palsy
– Tremor
– Multisystem atrophy – Hemiballism
– Olivopontocerebellar degeneration
(sporadic form)
– Palatal myoclonus
– Striatonigral degeneration • Intermediate
– Shy-Drager syndrome – Dystonia
– Diffuse Lewy body disease
– Corticobasal degeneration – Myokymia
– Drug-induced parkinsonism – Athethosis
– Dopa responsive dystonia
– Tic
• Other non-Parkinson's akinetic-rigid
syndromes – Stereotypy
• Huntington's disease (rigid or juvenile – Myorythmia
form) • Fleeting/unpredictable
• Wilson's disease
– Fasciculations
• Essential tremor
• Depression
– Myoclonus
• Arthritis, polymyalgia, fibromyalgia – Chorea
ERS
– Dyskinesias 53

51. 54
Bradley, 2010
ERS

52. 55
Bradley, 2010
ERS

53. Adams & Victor’s, 2005
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54. 57
Bradley, 2010
ERS

55. Disorder of Stance & Gait
Adams & Victor’s, 2005
ERS 58

56. Disorder of Stance & Gait
Adams & Victor’s, 2005
ERS 59

57. Bradley, 2010
ERS 60

58. Apraxia
http://thebrain.mcgill.ca
Bradley, 2010
ERS 61

59. Bradley, 2010
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60. Bradley, 2010
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61. Finally, it should be remarked once again that
the complexity of motor activity is
almost beyond imagination.
Adam & Victor, 2005
ERS 64