Download Neurology-Extrapyramidal Disorders

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Neurology-Extrapyramidal Disorders
What would be expected in Hxx of pt with
an extrapyramidal disorder?
What would you expect to see from
observation of a pt with an extrapyramidal
disorder?
Slow progressive onset, Often starts unilateral progresses to
become bilateral. Responds to medication initially.
Movement disorders,: twitches, jerks,
Hemiballismus (rare movement disorder caused by brain
lesion involves involuntary flinging motions of the
extremities)
What would the tone be like? (resistance to Cog-wheel rigidity is highly indicative of an extrapassive movement)
pyramidal condition
Would there be changes to power?
No reason for it to cause power change unless pt
immobilised
Would the reflexes be different in
Tendon reflexes-Can be slightly increased, if tone is very
extrapyramidal conditions?
high can be reduced. But not clonic.
Superficial cutaneous reflexes-normal so down going
plantar response!
Would sensation be affected?
No it would be normal-NB limbs may feel different because
of different tone (‘my leg feels like wood’ etc)
Would coordination be affected?
Affects coordination itself, as in movement initiation and
smooth, accurate execution
Differentiate between Pyramidal vs. Extrapyramidal structures + functions
Pyramid tract- Both the corticospinal and corticobulbar tracts. The corticospinal tract is a collection of
axons that travel between the cerebral cortex of the brain and the SC. It contains mostly motor axons. It
consists of 2 separate tracts in spinal cord: lateral corticospinal tract and anterior corticospinal tract. An
understanding of these tracts leads to an understanding of why one side of the body is controlled by the
opposite side of the brain. The corticobulbar tract is also a pyramidal tract, carrying information to motor
neurons of the cranial nerve nuclei, rather than the spinal cord.
Extrapyramidal - part of motor system that causes involuntary reflexes and movement, and modulation of
movement (i.e. coordination). The system is called "extrapyramidal" to distinguish it from the tracts of the
motor cortex that reach their targets by traveling through the "pyramids" of medulla. Tracts are
Vestibulospinal Tracts, Rubrospinal Tract, Reticulospinal System, Tectospinal Tract and Descending
Autonomic System.
Give an overview of their part
in the control of movement
and gait
Pyramidal pathways- corticospinal and some corticobulbar tracts, may
directly innervate motor neurons of SCor brainstem (anterior (ventral)
horn cells or certain cranial nerve nuclei), whereas the extrapyramidal
system centers around modulation and regulation (indirect control) of
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Predict possible sources of
confusion between UMNL
and extrapyramidal
dysfunction.
What part of the brain is
affected by Parkinsonism?
Describe the Clinical
Presentation of Parkinsonism.
What should you ask the pt if
you suspect Parkinsonism?
Describe signs of
Parkinson’s.
How severe is Parkinson’s
and what is the prognoses?
Describe signs, symptoms,
severity and management of
choreo-athetosis
anterior (ventral) horn cells. Extrapyramidal tracts-chiefly found in
reticular formation of the pons and medulla, and target neurons in SC
involved in reflexes, locomotion, complex movements, and postural
control. These tracts are in turn modulated by various parts of the CNS,
including the nigrostriatal pathway, the basal ganglia, the cerebellum, the
vestibular nuclei, and different sensory areas of the cerebral cortex. All of
these regulatory components can be considered part of the extrapyramidal
system, in that they modulate motor activity without directly innervating
motor neurons.
UMNL tendon reflexes are hyper-reflexic, brisk, at worst ‘clonic’ (hit
tendon and produce clonus) whereas extrapyramidal tendon reflexes can
be slightly increased, if tone is very high can be reduced. But not clonic
Superficial reflexes are not affected in extrapyramidal dysfunction; if
superficial reflexes are affected in UMNL they will be reduced or
infantile. The tone in UMNL changes to clonus/’stiff/wooden/leaden’ but
in extrapyramidal tone changes to cog-wheel rigidity.
De-pigmentation and loss of neurones in the substantia niagra and
depletion of dopamine-producing cells.
Slurring or hesitation of speech; excess salivation, infrequent blinking,
loss of facial expression and infrequent smiling,
Have you noticed anything different about handwriting?
Writing would be small (micrographia)
Can you turn over in bed?
Partner may recall being woken
Do you have difficulty walking?
Pt may report being stuck to the floor, may have noticed walk better on
uneven ground as here must be a deliberate ‘pyramidal function’.
Pill rolling tremor, mms rigidity (cog wheel).
Bradykinesia (Slowed ability to start and continue movements, and
impaired ability to adjust the body's position) affecting face and axial
mms first. Loss of postural reflexes.
Not fatal but tremor, bradykinesia and rigidity deteriorate simultaneously
affecting every aspect of the patient’s life. 50% suffer from depression,
80% develop dementia after 20 years if they survive.
Chorea is irregular, repetitive, jerking movements. Can be hereditary
(huntingtons), or caused by drugs, infection or immunological causes
such as SLE. The pathology is neuronal loss in the stratium with
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reduction on projections into other basal ganglia structures. Athetosis is
irregular, repetitive writing movements; picture shows hand movements
that occur.
Describe hemibalismus.
What could cause
hemibalismus?
Involuntary flinging motions of the extremities, and random and can
involve proximal and/or distal muscles on one side of body. The more a
patient is active, the more the movements increase
Damage to basal ganglia from stroke, traumatic brain injury, neoplasm
(basal ganglia are a collection of nuclei that connects to several other
areas of the brain. Due to the diverse nuclei that they contain, the basal
ganglia are involved in numerous functions, including motor control).
Hemiballismus caused by lesions in the subthalamic nucleus is more
severe than other forms of disorder
Describe tics (picture shows
facial tic)
Involved with the dopaminergic system in basal ganglia. Sudden,
repetitive, nonrhythmic motor movement or vocalization involving
discrete muscle groups. Tics can be invisible to the observer, such as
abdominal tensing or toe crunching. Common motor and phonic tics are,
respectively, eye blinking and throat clearing
What can osteopathy do about
Parkinson’s?
Gait re-education, improvement of balance and flexibility
Enhancement of aerobic capacity
Improvement of movement initiation
Improvement of functional independence, including mobility and
activities of daily living
Provision of advice regarding safety in the home environment
(from NICE guidelines on Physiotherapy ttt of Parkinson’s)
Anti-gravity muscles (extensors of the lower limb & flexors of the upper
limb) are spared. Pt can develop posture of flexed & pronated arms with
clenched fingers & extended & abducted legs w plantar flexion of the feet
- Turner
What is pyramidal pattern
weakness?
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Clinical features of
extrapyramidsl disease
What can hemibalismus be
caused by?
Predict possible sources of
confusion in relation to
UMNL
Pyramidal System
Where are the pyramids of the
brain?
Pyramidal System. What is its
structure?
What is it function?
What is pyramidal pattern
weakness?
Generally seen as disorder of movement can be divided into 2 categories:
Decreased Movement
Postural disturbance: failure to make quick postural adjustments. Patient
often falls. Flexion of limbs and trunk is associated with this
Bradykinesia: a loss or slowness of voluntary movement
Mask like face
Reduced blinking
Reduced adjustments of posture when sitting
Increased Movement
Myoclonus (shock like jerks)
Rigidity – stiffness of limbs (During passive movement can be felt
throughout the ROM & equally in flexors & extensors = Plastic/Lead
Pipe Rigidity)
Tremor
Ballisimus (explosive, violent movements)
Chorea (repetitive, irregular, jerking movements)
Dystonia (slow, sustained, abnormal voice)
Infarction or haemorrhage in the conralateral subthalamic nucleus - turner
Vascular disease
Multiple Sclerosis
Damage to the descending motor pathways anywhere along the trajectory
from the cerebral cortex to the lower end of the spinal cord gives rise to a
set of symptoms called the "Upper Motor Neuron Syndrome".
The UMN neurons pass through both the pyramid and extra pyramidal
tracts
UMN lesions occurring within the pyramidal tracts of brain or spinal cord
create patterns of pyramidal weakness (loss of power in extensors of arms
and flexors of legs. Anti-gravity muscles are spared.)
The rigidity that occurs in Extrapyramidal disorders could be confused
with a UMNL
Anterior potion of the medulla oblongata
The pyramidal tract (aka Corticospinal) travels between the cerebral
cortext of the brain & the spinal cord (via the pyramid of the medulla). –
wiki & lawrence
The Corticospinal tract is concerned specifically with discrete voluntary
skilled movements, especially of the distal parts of the limbs. – Wiki
“motor system which is used to make conscious movement. Largely
centered around the corticospinal tract which passes through the
pyramids of the medulla oblongata - Lawrence
Anti-gravity muscles (extensors of the lower limb & flexors of the upper
limb) are spared. Pt can develop posture of flexed & pronated arms with
clenched fingers & extended & abducted legs w plantar flexion of the feet
- Turner
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