Het motorisch actiesysteem – Inleiding PDF

Het motorisch actiesysteem – Inleiding LP - Neurale basis voor het functioneren OPO Functioneren bij neurologische aandoeningen Prof. Dr. Peter Feys UMN – LMN ▪ Cortical (pre)motor cortex ▪ Basal Ganglia & Cerebellum ▪ Upper Motor Neuron (UMN) ▪ Spinal interneurons ▪ L...

Het motorisch actiesysteem – Inleiding LP - Neurale basis voor het functioneren OPO Functioneren bij neurologische aandoeningen Prof. Dr. Peter Feys UMN – LMN ▪ Cortical (pre)motor cortex ▪ Basal Ganglia & Cerebellum ▪ Upper Motor Neuron (UMN) ▪ Spinal interneurons ▪ Lower Motor Neuron (LMN) ▪ Peripheral and cranial nerves Uit: Lundy-Ekman 10.1 Anatomische kenmeren van UMN - LMN ❑ Upper Motoneuronen UMN (= centrale motor neuronen): ❑ neurale nucleus in de hersenen en hersenstam ❑ waarvan de axonen in het CZS blijven ❑ synapteren met de LMN. ❑ Lower Motoneuronen LMN (= perifere motor neuronen): ❑ Neurale nucleus in hersenstam en ruggenmerg ❑ waarvan de axonen het CZS verlaten ❑ synapteren met spiervezels ❑ 31 spinale zenuwen clusterend tot perifere zenuwen (vb. N. tibialis, N. radialis, …) ❑ Craniale zenuwen (vb. N. facialis, N. trigeminus-motor part, N Hypoglossus …) UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 7th edition. Table 5.9 MS, …. 6 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 8th edition. Table 5.13 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan. Table 5.9 MS, …. 8 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 7th edition. Table 5.9 MS, …. UNI 1 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 8th edition. Table 5.13 2 Introduction ▪ Force production - Musculoskeletal properties - Neural activation - Numer of motor units recruited - Type of motor units recruited - Discharge frequency ▪ Muscle weakness - Inability to generate normal levels of force - Paresis: mild or partial loss - Paralysis or Plegia: total loss  UMN STRENGTH LMN UMN lesion: LMN lesion: - Verspreide parese-paralyse/plegia Ipsilaterale focale parese of paralyse - Contra- of ipsilateraal segmentaal of perifere zenuwen niveau. (boven of onder pyramis) vb. C6 = Wrist extensors (ASIA) n. Radialis = polsstrekkers  UMN Stroke, TBI Muscle paresis or paralysis ▪ contralateral of the lesion ▪ Ipsilateral side Shumway-Cook, fig 3.13 5 Taxonomy Het motorisch actiesysteem – Inleiding LP - Neurale basis voor het functioneren OPO Functioneren bij neurologische aandoeningen Prof. Dr. Peter Feys UMN – LMN ▪ Cortical (pre)motor cortex ▪ Basal Ganglia & Cerebellum ▪ Upper Motor Neuron (UMN) ▪ Spinal interneurons ▪ Lower Motor Neuron (LMN) ▪ Peripheral and cranial nerves Uit: Lundy-Ekman 10.1 Anatomische kenmeren van UMN - LMN ❑ Upper Motoneuronen UMN (= centrale motor neuronen): ❑ neurale nucleus in de hersenen en hersenstam ❑ waarvan de axonen in het CZS blijven ❑ synapteren met de LMN. ❑ Lower Motoneuronen LMN (= perifere motor neuronen): ❑ Neurale nucleus in hersenstam en ruggenmerg ❑ waarvan de axonen het CZS verlaten ❑ synapteren met spiervezels ❑ 31 spinale zenuwen clusterend tot perifere zenuwen (vb. N. tibialis, N. radialis, …) ❑ Craniale zenuwen (vb. N. facialis, N. trigeminus-motor part, N Hypoglossus …) UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 7th edition. Table 5.9 MS, …. 6 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 8th edition. Table 5.13 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan. Table 5.9 MS, …. 8 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 7th edition. Table 5.9 MS, …. UNI 1 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 8th edition. Table 5.13 2 Introduction ▪ Force production - Musculoskeletal properties - Neural activation - Numer of motor units recruited - Type of motor units recruited - Discharge frequency ▪ Muscle weakness - Inability to generate normal levels of force - Paresis: mild or partial loss - Paralysis or Plegia: total loss  UMN STRENGTH LMN UMN lesion: LMN lesion: - Verspreide parese-paralyse/plegia Ipsilaterale focale parese of paralyse - Contra- of ipsilateraal segmentaal of perifere zenuwen niveau. (boven of onder pyramis) vb. C6 = Wrist extensors (ASIA) n. Radialis = polsstrekkers  UMN Stroke, TBI Muscle paresis or paralysis ▪ contralateral of the lesion ▪ Ipsilateral side Shumway-Cook, fig 3.13 5 Taxonomy UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan. Table 5.9 MS, …. UNI 1 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 8th edition. Table 5.13 UMN TONUS LMN UMN lesion: LMN lesion: - Hypertonie Hypo- of atonie  Shumway-Cook Hfst 5. Figuur 5.4 TONUS - Range ▪ Muscle resistance to passive stretch ▪ A certain level of tone is typical in normal muscles Hypotonie Hypertonie Normaal bewegen LMN lesion UMN lesion Basal Ganglia Cerebellar lesion dysfunction TONUS - Range Fell. Lifespan Neurorehabilitation, FA Davis. fig 6.11 HYPERTONIE Normaal Hypotonie bewegen Hypertonie - ‘spastic’ hypertonia: Snelheidsafhankelijk (UMNL) - ‘rigid’ hypertonia: niet-snelheidsafhankelijk (vb. loden pijp/tandrad bij Parkinson, basale ganglia dysfunction) Spastic hypertonia ▪ Lesion in the descending motor pathways ▪ Corticospinal (pyramidal) tract ▪ Cortico-reticulo-spinal tract ▪ Increased alpha motor neuron excitability resulting in increased ▪ Muscle tone tonic stretch reflex activity ▪ Exaggerated tendon jerks phasic stretch reflexes SPASTICITY: what’s in a name? 1. Working definition of Lance 1980, neurophysiological See also Shumway-Cook Hfst 5 “Spasticity is a motor disorder characterized by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome” 2. Definition by O’Sullivan “Spasticity is a motor disorder characterized by a velocity- dependent increase in muscle tone with increased resistance to stretch. The larger and quicker the stretch, the stronger the resistance of the spastic muscle’ Proxy evaluation of muscle tone Pendulum or drop test ▪ Normally dropping to about 70 degrees knee flexion ▪ Pendulum about 6x Shumway-Cook fig 5.10 Fell fig 6.11 Testvolgorde Mogelijke musculaire verkorting 1. totale ROM meten (passief & traag) 2. snelle beweging ter beoordeling van hypertonie evaluatie van de spier die je verlengt Lundy-Ekman 13.17 Fell 6.9 Hypertonie: verschijningsvormen ▪ Catch: temporary resistance to movement ▪ Hypertonia in (part of) ROM ▪ Clasp knife phenomenon: glossary Fell ▪ Clonus (≈ ‘reflex’): glossary Glossary: in ‘Lifespan Neurorehabilitation’ Fell Evaluation of muscle tone : Aschworth & Tardieu Fell. Lifespan Neurorehabilitation, FA Davis. Table 6-9, 6-10 See also: Shumway-Cook 5.1; O’Sullivan 5.4; TYPISCH PATROON van TONUSVERHOGING bij UMN (CVA) BOVENSTE LIDMAAT Retracted O’Sullivan & Schmitz  TYPISCH PATROON van TONUSVERHOGING bij UMN O’Sullivan & Schmitz 8th edition. 5.4 TYPISCH PATROON van TONUSVERHOGING bij UMN, Vb. CVA: BOVENSTE LIDMAAT O’Sullivan & Schmitz, 7th edition TYPISCH PATROON van TONUSVERHOGING- OL limb 16 O’Sullivan TYPISCH PATROON van TONUSVERHOGING- OL limb Prolonged sitting position Trunk 17 O’Sullivan ‘Spastische parese’ ▪ Spierzwakte in triceps EN/OF hypertonie in biceps 18 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan. Table 5.9 MS, …. UNI 1 UMN lesion- involuntary movements: SPASMS  Plotse onwillekeurige bewegingen Meestal onderste ledematen  flexie spasms (vnl fasisch) extensie spasms (vnl tonisch)  Spasmen uitlokbaar door externe prikkels  Vb. snelle beweging (proprioceptief), huidcontact (exteroceptief), pijn/incontinentie (interoceptief)... LMN-lesion: Involuntary movements: Fasciculaties & Fibrillations Involuntary muscle contractions: quick twitches of muscle fibers of a single motor unit that are visible (fasciculaties) or not visible (fibrillations) on the surface of the skin. Fasciculaties typisch bij voorhoornaandoeningen (bijvoorbeeld ALS = amyotrofe lateraal sclerose) UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan. Table 5.9 MS, …. UNI 1 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan 8th edition. Table 5.13 UMN TONUS LMN UMN lesion: LMN lesion: - Hypertonie Hypo- of atonie  Shumway-Cook Hfst 5. Figuur 5.4 TONUS - Range ▪ Muscle resistance to passive stretch ▪ A certain level of tone is typical in normal muscles Hypotonie Hypertonie Normaal bewegen LMN lesion UMN lesion Basal Ganglia Cerebellar lesion dysfunction TONUS - Range Fell. Lifespan Neurorehabilitation, FA Davis. fig 6.11 HYPERTONIE Normaal Hypotonie bewegen Hypertonie - ‘spastic’ hypertonia: Snelheidsafhankelijk (UMNL) - ‘rigid’ hypertonia: niet-snelheidsafhankelijk (vb. loden pijp/tandrad bij Parkinson, basale ganglia dysfunction) Spastic hypertonia ▪ Lesion in the descending motor pathways ▪ Corticospinal (pyramidal) tract ▪ Cortico-reticulo-spinal tract ▪ Increased alpha motor neuron excitability resulting in increased ▪ Muscle tone tonic stretch reflex activity ▪ Exaggerated tendon jerks phasic stretch reflexes SPASTICITY: what’s in a name? 1. Working definition of Lance 1980, neurophysiological See also Shumway-Cook Hfst 5 “Spasticity is a motor disorder characterized by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome” 2. Definition by O’Sullivan “Spasticity is a motor disorder characterized by a velocity- dependent increase in muscle tone with increased resistance to stretch. The larger and quicker the stretch, the stronger the resistance of the spastic muscle’ Proxy evaluation of muscle tone Pendulum or drop test ▪ Normally dropping to about 70 degrees knee flexion ▪ Pendulum about 6x Shumway-Cook fig 5.10 Fell fig 6.11 Testvolgorde Mogelijke musculaire verkorting 1. totale ROM meten (passief & traag) 2. snelle beweging ter beoordeling van hypertonie evaluatie van de spier die je verlengt Lundy-Ekman 13.17 Fell 6.9 Hypertonie: verschijningsvormen ▪ Catch: temporary resistance to movement ▪ Hypertonia in (part of) ROM ▪ Clasp knife phenomenon: glossary Fell ▪ Clonus (≈ ‘reflex’): glossary Glossary: in ‘Lifespan Neurorehabilitation’ Fell Evaluation of muscle tone : Aschworth & Tardieu Fell. Lifespan Neurorehabilitation, FA Davis. Table 6-9, 6-10 See also: Shumway-Cook 5.1; O’Sullivan 5.4 (7th edition) or 5.5 (8th edition) TYPISCH PATROON van TONUSVERHOGING bij UMN (CVA) BOVENSTE LIDMAAT Retracted O’Sullivan & Schmitz  TYPISCH PATROON van TONUSVERHOGING bij UMN O’Sullivan & Schmitz 8th edition. 5.4 TYPISCH PATROON van TONUSVERHOGING bij UMN, Vb. CVA: BOVENSTE LIDMAAT O’Sullivan & Schmitz, 7th edition TYPISCH PATROON van TONUSVERHOGING- OL limb 16 O’Sullivan TYPISCH PATROON van TONUSVERHOGING- OL limb Prolonged sitting position Trunk 17 O’Sullivan ‘Spastische parese’ ▪ Spierzwakte in triceps EN/OF hypertonie in biceps 18 UMN-LMN LESION: Klinisch beeld Uit: O’Sullivan. Table 5.9 MS, …. UNI 1 VOLUNTARY MOVEMENTS also called ‘frationation’ or ‘individuation’ Schumway-Cook Hfst 5 & O’Sullivan Glossary Fell (Lifespan Neurorehabilitation) VOLUNTARY MOVEMENTS Fell (Lifespan Neurorehabilitation) UMN lesion: loss of selective motor control Abnormal coupling of related muscles defined as movements that are primitive and highly stereotyped (O’Sullivan) cannot be changed or adapted to changes in the tasks or environmental demands Schumway-Cook Hfst 5 & O’Sullivan Glossary Fell (Lifespan Neurorehabilitation) UMN lesion: loss of selective motor control Lifespan Neurorehabilitation, figure 6-18 Abnormal SYNERGIES in UMNL Wrist extension or flexion Shumway-Cook- Hfst 5. 7th edition. See also Fell, Table 6-14 Abnormal SYNERGIES in UMNL O’Sullivan – Hfst 15 Stroke 8th edition. See also Fell, Table 6-14 Abrnomal Flexor Synergy. Case: Person post middle cerebral artery stroke interrupting the left hemipshere corticospinal tracts. Her intent is to raise both upper limbs overhead. She is unable to combine shoulder flexion with elbow extension. Descending signals from the reticulospinal tract activate lower motor neurons to (proximal) muscles that produce abnormal synergy in the right upper limb. Lundy-Ekman Fig 14-17 Reticulospinal tract & proximal muscles Lundy-Ekman Fig 14.2 Fugl-Meyer assessment Evaluation of Upper & Lower Limb - Reflexes - Moving in synergies - Moving out of synergies - Individuation – selective movements - Coordination - Sensory function Maximal score UL = 66 Maximal score LL = 34 O’Sullivan 7th edition – appendix Hfst 15. Stroke Het motorisch actiesysteem – Pathologie, illustratie LP - Neurale basis voor het functioneren OPO Functioneren bij neurologische aandoeningen Prof. Dr. Peter Feys UMN-LMN LESION : syndroom kenmerken MS, …. 2 O’Sullivan Toepassing UMN – LMN volgens ziektebeelden ▪ Cerebrovasculair accident (CVA) Beroerte- stroke ▪ Dwarsleasie ≈ Spinal Cord Injury (SCI) ▪ Cerebro-Craniaal Trauma (CCT) ≈ Traumatic Brain Injury (TBI) 3 TONUS, REFLEXES IN PATHOLOGIES WITH UMNL & LMNL LMN lesion UMN lesion Basal Ganglia Cerebellar lesion dysfunction Fell. Lifespan Neurorehabilitation, FA Davis. fig 6.11 Pathologieen en plaats van mogelijke motorische stoornissen Fell. Lifespan Neurorehabilitation, FA Davis. Box 6.1 Severe CEREBRAL DAMAGE ➔ Spastic Hypertonia Sometimes in TBI = traumatic brain injury Decorticate “rigidity” Decerebrate “rigidity“ due to severe lesions superior to due to severe midbrain lesions the midbrain Extension of trunk/all limbs, Extension of neck, legs, plantair internal rotation & pl flexion flexion & flexion of arms Fell. Lifespan Neurorehabilitation, FA Davis. Figuur/Tabel 6.11 STROKE, TBI, MS - UMN SCI – UMN & LMN mogelijk Spinal cord injury Motorisch niveau C6: Hoge tetraplegie C6-T1: Lage tetraplegie T2-T5: Hoog-thoracale paraplegie T6-T9: Mid-thoracale paraplegie T10-T12: Laag-thoracale paraplegie L: lumbale paraplegie S: sacrale paraplegie Vertoont iedereen altijd spasticiteit? Wanneer/waar slappe parese? Voorspelbaar bij anatomische letsels van traumatische oorsprong “ Een patiënt met een traumatisch letsel van het cervicale ruggenmerg vertoont altijd spasticiteit. “ UMN lesion “Een patiënt met een traumatisch letsel caudaal van wervelzuilniveau L1- L2 vertoont altijd een volledige slappe parese.“ LMN lesion --- focale spierverlamming volgens Myotoom “Een patiënt met een traumatisch letsel tussen cervicaal en wervelovergang L1-L2 kunnen een gemengd type vertonen (spastische en slappe parese).“  Lesion in the Central Nervous System U.M.N. - lesion L.M.N. - lesion - Spierzwakte Spierzwakte (lokaal) + hypertonie atonie Areflexie + hyperreflexie atrofie + pathologische reflexen Spastische dwarsleasie Slappe dwarsleasie Different brain regions connected to pathologies Stroke, TBI - UMN Parkinson –basal ganglia Cerebellar disease - cerebellum Spinal cord injury – UMN/LMN 20 O’Sullivan