Approach to Motor Weakness Dr Rashmi Kumar Professor, Pediatrics KGMU
Jan 02, 2016
Approach to Motor Weakness
Dr Rashmi Kumar
Professor, Pediatrics
KGMU
PathwaysTypes of weakness
Upper motor neuronLower motor neuron
Localization of lesionPatterns of weakness
monoplegiahemiplegiaparaplegiaquadriplegiadiplegia
Cerebral palsy
MOTOR WEAKNESS:
• Types & pattern
• Anatomical localization
• Etiology
History
• Onset
• Course
• H/o fever
• H/o seizures
• Developmental milestones
Examination
• Young child - ‘observation’• Older child - ‘play’ Gait & Posture Muscle mass Tone Power Coordination Abnormal movements Reflexes –superficial & deep
Examination:
Posture– Frog leg– Scissoring– Decerebrate/decorticate/ophisthotonus– Others
Gait– Foot drop– Circumduction– Limp– Waddling
Examination:Muscle mass:• Compare 2 sides• Measure in relation to fixed points in lower motor neuron• Slightly in upper motor neuronMuscle Tone in LMN, cerebellar lesions in UMN• physiological in newborn• frog leg position/scissoringMuscle power• maximum strength maybe impossible to test in uncooperative
children• normal strength in pure cerebellar/basal ganglia lesions
Infant/toddler: ‘observation’• definite hand preference before 2 yrs
suspicious• hemiplegic arm flexed at elbow,
movement, fisting with thumb adduction• asymmetric developmental reflexes• lift with hands under arms• traction
Older child: Quick assessment• hold arms over head• walk on heels & toes• get up from floor• run• hop on 1 foot• press arms against wall• squeeze finger• circumduction of thumb• formal testing
Types of motor weakness:• above anterior horn cell – UMN
• below – LMN (final common pathway)
UMN LMN
M mass Slightly dt disuse severely
M tone spastic flaccid
M power
Distribution Individual Mm never affected
Individual Mm maybe affected
DTRs lost
Babinski absent
Superficial reflexes Lost (maybe regained later)
lost
Localisation of lesion: UMNMOTOR CORTEX:• u/l weakness of opposite distal hand, leg or lower face• proximal muscles mb transiently weak• seizures mb+• gaze palsies (area 8 inv)• aphasia (Brocas area –left side)• cranial nerves, trunk muscles not affected dt b/l innervation
Internal Capsule:• dense hemiplegia• dystonia
Midbrain• ‘crossed’ paralysis• ipsilateral IIIrd nerve + contralateral hemiplegia
Pons• ‘crossed’ paralysis• ipsilateral Vith/VIIth nerve palsy + contralateral hemiplegia• Involvement of reticular activating system – altered consciousness
Localisation of lesion : UMNMedulla• ‘crossed’ paralysis• ipsilateral XII th nerve palsy + contralateral hemiplegia• Involvement of reticular activating system – altered consciousness
Spinal cord• LMN signs at level of lesion• UMN signs below
Acute destructive lesions of UMN hypotoniaAll cranial nerves have b/l representation except
part of VII & XII
The Final Common Pathway
Localisation of lesion: LMNSpinal Cord lesion:• LMN signs at level of lesion + UMN signs below• Acute lesions spinal shock recovery in few weeks• Bladder & bowel involvement
Anterior horn cell/ventral root/plexus lesions:• Weakness in specific myotomes• Slow degeneration of anterior horn cells fasciculations
Peripheral Nerves:• Single nerve lesion mononeuritis –weakness in distribution• Polyneuritis:
– Distal weakness– Early loss of reflexes – may not correlate with degree of weakness
Neuromuscular junction:• Prediliction for ocular/pharyngeal or proximal muscles• Reflexes lost late in affected muscles Muscle:• Proximal weakness• Deep reflexes maybe but elicitable• Myotonia in some
LEVEL
SC PN NMJ M Weakness ++ +/- +/- + DTRs - - - (early) (late) Distribution upper level distal ocular+ proximal or patchy pharyngeal fasciculations + - - - (in chronic degenerative disorder)tone NCV n n nEMG fibrillations ,, fatigue pattern BSAPP amplitude of MUP
•
Patterns of Weakness:• MONOPLEGIA – weakness of a limb• Lesion often cortical, vascular in etiology• Sometimes, peripheral n lesion• • HEMIPLEGIA – weakness of upper & lower limbs on same side• Usually UMN• Lesion at cortex, internal capsule• Sometimes, brain stem/SC lesions Signs: • hand preference before 2 yrs of age• circumduction gait• asymmetrical reflexes• hemiplegic hand kept flexed at elbow, fisted with adducted thum Causes:• Hemiplegic cerebral palsy• Todds palsy Tumour• Trauma
MigraineAbscessGranulomaVascular - Stroke :Sudden onset -- > gradual recovery
Stroke in ChildhoodIschemic-sudden Hemorrhagic- severe headache, s/o
ICT, meningeal signsInfections – PM, TBM, NCC, tuberculoma, VE, abscess
o
Cardiac – CHD, RHD, SABE
o
Collagen vascular disorders – SLE, PAN, APS
o
Hematologic – Sickle cell disease,leukemia, dehydration, iron deficiency, hypercoagulable states,
o
Metabolic
Idiopathic - 'acute infantile hemiplegia' -mb dt trauma to internal carotid
Vascular – AV malformation, aneurysm
Hypertension
Bleeding diatheses
Vit K deficiency
PARAPLEGIA: Weakness of both lower limbs
• Lesion in SC or PN (polyneuritis)
• UMN type – lesion in SC. If acute may spinal shock
• LMN type -
- lesion in lower SC eg. myelomeningocele
- spinal shock stage
- polyneuritis eg GBS, post diptheretic palsy
- NM junction
- Muscle
SPINAL CORD LESIONS:• I Compressive Acute – trauma, epidural abscess• Chronic –tumour, vertebral disease, syringomyelia, arachnoiditis• • II Non compressive• Acute – TM, hematomyelia, infarction, infections, post infectious• Chronic – degenerative • -spinocerebellar degenerations• -spinal muscular atrophy• -motor neuron disease• -subacute combined degeneration
Chronic lesions may present acutely dt secondary vascular changes
QUADRIPLEGIA- weakness of all 4 limbs Deep coma Lesions of brain stem Upper SC UMN signs Polyneuritis All causes of paraplegiaCraniovertebral malformations DIPLEGIA- weakness of both arms or both legs• Cerebral diplegia – a form of CP seen in premature babies
Cerebral Palsy:
• MOTOR defect due to non progressive cerebral disorder acquired in early life
• 2/1000• Maybe associated with MR, seizures, hyperactivity etc.• • ETIOLOGY:• Prenatal- radiation, drugs,infections, malformations• Natal – LBW, trauma, asphyxia, ischemia• Post natal – kernicterus, neonatal illness, hypoglycemia, CNS
infections
• No cause found in ¼
Cerebral Palsy:• DIAGNOSIS:• Delayed motor development• Abnormal persistence of developmental reflexes• Feeding problems• TYPES:• Spastic • quadriplegia • - most common• - severe disability, MR• - pseudobulbar palsy feeding problems• - extrapyramidal signs• - multicystic encephalomalacia• Hemiplegia• - related to perinatal events – PIH, ischemiastroke• - porencephaly• Diplegia• - prematurity periventricular leukomalacia• Dyskinetic – kernicterus, circulatory failure, asphyxia Ataxic – often due to unrecognized cerebellar malformation
•
MANAGEMENTMultidisciplinary approach with involvement of
neurologist, physiotherapist, speech therapist, occupational therapist
Drugs to reduce tone , appliances