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UPPER MOTOR NEURON SYNDROME

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Presentation on theme: "UPPER MOTOR NEURON SYNDROME"— Presentation transcript:

1 UPPER MOTOR NEURON SYNDROME

2 Aims Expand the participants’ understanding of upper motor neuron syndrome. Introduce the application of the concepts of movement as used in the assessment and treatment of adults in the analysis posture and movement.

3 Motor Neuron Upper motor neuron
- cell body lives in a CNS processing center synapses on the lower motor neuron activity in upper motor neuron may facilitate or inhibit lower motor neuron Lower motor neuron cell body lives in a nucleus of the brain stem or spinal cord triggers a contraction in innervated muscle: destruction of or damage to lower motor neuron eliminates voluntary and reflex control over innervated motor unit motor neuron upper motor neuron -cell body가 cns에 존재한다. -lower motor neuron과 시냅스한다. -upper motor neuron을 활성화하면 lower motor neuron은 활성화되거나 억제된다. lower motor neuron -cell body가 brain stem이나 spinal cord의 핵에 존재한다. -innervate된 muscle의 수축의 계기가 된다. -lower motor neuron이 손상될 시 innervate된 motor unit의 voluntary한 움직임이 없어지며 반사가 조절되지 않는다.

4 Upper Motor Neuron upper motor neuron upper motor neuron은 brain 그리고 motor cortex와 같은 상위 중추에 시작되는 neuron이며 lower motor neuron과 시냅스하여 움직임과 같은 명령을 descending 으로 전달한다. Upper motor neurons are neurons that originate in higher regions of the brain, such as the motor cortex, and synapse on the lower motor neurons to convey descending commands for movement (Mayer 2003)

5 Lower Motor Neuron Lesions
Impaired reflex actions -causes flaccidity atrophy -can grow back 1 mm a day lower motor neuron 병변 반사적 운동의 손상 flaccidity가 야기된다. atrophy 다시 돌아올 수 잇다. 하루에 1mm

6 Amyotrophic Lateral Sclerosis
루 게릭 als는 기본적 것 조차 불가능하게 되는 고통을 받는다. Lou Gehric, July 4, 1939

7 UMN Syndrome Damage to the descending motor
pathways anywhere along this trajectory gives rise to a set of symptoms umn 신드롬 descending motor pathway가 손상된다....

8 Upper motor neuron syndrome
Following a brain injury an individual will often have a complex presentation impacting not only on the neuromuscular system but also on the musculoskeletal, sensory-perceptural and cognitive system (Cohon 1999) The upper motor neuron syndrome encompasses all the dyscontrol characteristics associated with a lesion affecting some or all of the descending motor pathway (Barnes 2001) Motor dysfunction after UMN lesion is classified into positive and negative signs. (Canning et al. 2004)

9 Negative & Positive Signs
hughlings jackson Hughlings jackson (1835~1911)

10 UMN Syndrome Negative signs are those represent a loss of
Pre-existing function. Positive signs relate to secondary changes (Canning et al. 2004) This classification does not encompass cognitive or Perceptual dysfunction or psychological reaction. Umn 신드롬 Negative sign은 그전의 활성화된 기능이 감소되는 것을 나타낸다. Positive sign은 다시 변화된 것과 관련된 것을 의미한다. 이 분류는 인지 및 지각 그리고 심리학적인 요소는 해당되지 않는다.

11 Non-neural changes in muscle
UMN Syndromes Negative signs Positive signs Weakness Clonus Fatigue Associated reactions Sensory loss Non-neural changes in muscle Acute hypotonia Spasticity Loss of dexterity Hyperreflexia Umn 신드롬 Negative sign – weakness, fatigue, sensory loss, acute hypotonia, dexterity의 소실 Positive sign – clonus, AR, muscle의....., spasticity, Hyperreflexia

12 Weakness Constitutes a major cause of the patient’s disability.
- Reduced neural excitation may cause weakness. Muscular weakness may cause secondary weakness of neural transmission. Reduce muscle activation may cause atrophy and change in the muscle fiber population. Weakness -환자들의 disability를 일으키는 주된 원인이다. -신경학적인 활성화 감소로 약화가 야기된다. -근약화의 이차적인 문제는 신경학적 전달물질의 감소이다. -근육의 활성화 감소는 atrophy와 근섬유의 구성을 변화시킨다.

13 Weakness Muscle atrophy could be due to Disuse
Loss of central trophic effects Neurogenic atrophy Number of motor units reduced post stroke (Hura et al 2000) Muscle length associated with weakness at certain ranges Weakness Atrophy

14 Central Loss of Force Production
Loss of central command generate and sustain force. No loss of contractile capacity: not the same as peripheral weakness, myopathy or general weakness (Sahrmann 2002) Compensatory movement patterns

15 Action ↑ Cognition Perception Sensation

16 Sensory Deficits Deficits in awareness, processing and interpretation and kinesthetic memory Fewer attempts at spontaneous movements Altered sense of “weight” of a limb Altered sense of timing and speed Contributes to development of pain

17 Loss of Dexterity Ability to solve any motor task precisely, quickly, and deftly. To coordinate muscle activity to meet environmental demands.

18 Fatigue Many stroke patient suffer from fatigue.
Reduced force production causes an increase in the effort required to move. Weakness may be another reason for fatigue.

19 Associated Reaction Is the abnormal muscle activation during moving, be called dyssynergic pattern of movement. Indicate weak postural control mechanism and loss of the normal balance strategies. Occur in response to perturbation either intrinsic or extrinsic generation - Can change the muscle type from phasic to tonic. - Promote learned non-use.

20 Definition of spasticity
As…motor disorder characterised by a velocity dependent increase in the tonic stretch reflex(muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome (Lance 1980) What is frequently forgotten is that the Lance definition refers to only one component of the UMN syndrome (Ivanhoe & Reistetter 2004)

21 Spasticity Before the 1970’, spasticity was seen as the major contributors to disability. Excessive antagonist activity could not have caused the observed movement abnormality (Dietz et al. 1981, Sahrmann & Norton 1977).

22 Spasticity Exaggerated stretch reflexes may not be the major cause of established spasticity. Factors which are thought to contribute to the increased mechanical resistance to movement include reduced tendon compliance and physiological and histochemical change in muscle fiber (Dietz 1992)

23 Spasticity “Spasticity is a sensori-motor phenomenon related to the integration of the nervous system motor response to sensory input” “It is related to hypersensitivity of the reflex arc as a result of the loss of descending inhibition” (Ivanhoe & reistetter 2004)

24 Spasticity - Research definition is increment of muscle tone due to hyperexcitability of stretch reflex. Clinicians definition is much broader, includes the entire UMN syndrome. Misconception Hyperactive stretch reflex are cause of excess muscle stiffness and associated movement But hyperstiffness is often the result of nonreflexive factor : myoplasticity and/or muscle overactivity.

25 Alpha-gamma coactivation

26 New Definition “Disordered sensory-motor control resulting from an UMN lesion presenting as intermittent or sustained involuntary activation of muscles,” SPASM 2005

27 Mechanism of Hypertonia
CNS lesion Reflex hyperexcitability Altered muscle function (eg prolonged shortening) Hypertonia Non-CNS factors (eg immobilization) Altered passive mechanical Properties(contracture)

28 The Neurological Deficits
Primary Impairments Neurological weakness Muscle activation deficit Change in tone Composite Impairment Clinical hypertonicity (spastic movement disorder) Altered postural control Loss of selective movement Secondary Impairments Altered alignment Change in muscle length and position edema pain

29 Mechanical Impairment
Chemical Communication Neural Problem Non-Neural Problem Mechanical Impairment

30 IMPAIRMENT Secondary impairment Primary impairment
Composite impairment Movement deficits Atypical movement Compensation

31 Primary Impairment Changes in muscle strength
Changes in muscle / postural tone Changes in muscle activation Sensory changes

32 Secondary Impairment Orthopedic changes in alignment and mobility
- Changes in joint mobility Changes in muscle and soft tissue length

33 Composite Impairment (Movement dysfunction)
Movement deficits Atypical movement Compensation

34 References Shumway-Cook & Woollacott: Motor control. 2007
Janet M.Howel: Neuro-Development Treatment Approach. 2002 Eric C. Kandel: Principle of neural science Geoffrey Kidd MSc :Understanding Neuromuscular Plasticity.1992. Dr. Nigel Lawes , Ms Mary lynch-Ellerington: Changing the Nervous System “ From Cell to patient” Bente E. Bassoe Gjelsvik : The Bobath Concept in Adult Neurology Mary lynch-Ellerington : Bobath course note. 2006,2007,2010 Mary lynch-Ellerington, Sue Raine : Bobath Concept. 2009


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