NEUROLOGY –

UPPER MOTOR NEURON

LESIONS
MRS F.B.MALAMBO
 INTRODUCTION
• Adequate and effective control of posture,
mov and balance require intact pathways
for sensory information, integration and
motor output
• All purposeful movts are initiated and
guided through sensory information
which reaches the brain from wide variety
of receptors in the skin, muscles, joint,
ears and eyes.
• Neurological conditions either block
the transmission of smoothly
coordinated patterns to the muscles
or cause the brain to generate
aberrant synergies.
 Definition of terms
• A motor neuron is a neuron whose cell
body is located in the motor cortex,
brainstem or the spinal cord, and whose
axon (fiber) projects to the spinal cord or
outside of the spinal cord to directly or
indirectly control effector organs, mainly
muscles and glands to effectors.
 There are two types of motor neuron:
Upper motor neurons and lower motor neurons.
•Axons from upper motor neurons synapse onto
interneurons in the spinal cord and occasionally
directly onto lower motor neurons.
•The axons from the lower motor neurons are
efferent nerve fibres that carry signals from the
spinal cord the effectors.
 UPPER MOTOR NEURON LESION
Pyramidal insufficiency is Interruption of
the corticospinal and corticobulbar tract
along its course or neural pathway above
the anterior horn of the spinal cord and
or motor nuclei of the cranial nerves
(Corticospinal tract fibers synapse with
spinal nerves while corticobulbar fibers
synapse with cranial nerves).
• This can also be defined as
any damage to the motor
neurons that reside above
nuclei of cranial nerves or
the anterior horn cells of
the spinal cord.
 PREVALENCE AND
INCIDENCE
• According to the Global burden of
disease study 2016, there were 27.08
million cases of traumatic brain and
spinal cord injury, with the age-
standardized incidence rates of 369
per 100,000 populations, per year.
• AGE: Elders and children fall lot, RTA
common in middle group.
• SOCIOECONOMIC: Conflicts, politics
The childhood injuries are the most likely in the
poorest countries with W.H.O. claiming 98%
occurrence in low- and medium-income
countries and 5 times greater frequency than in
industrialized nations
• GEOGRAPHIC REGION: Low and middle
income countries.
• Affects men more than women
• The various types may have different risk
factors.
 Spinal muscular atrophy is always hereditary,
but this is not true for all forms of motor
neuron disorders
 footballers have a higher risk of dying from
ALS, Alzheimer's disease, and other
neurodegenerative diseases, compared with
other people.
 ETIOLOGY and types
• TRAUMA – Traumatic head injury and traumatic spinal
cord injury
• DEMYLINATING DISEASES- Amyotrophic lateral
sclerosis, Primary lateral sclerosis
• VASCULAR DISEASES-CVA,
• GENETIC- Hungtingtons, Spinal muscular atrophy
• TUMORS- CNS and PNS
• NEURODEGENERATIVE DISORDERS- Parkinsons
• AUTOIMMUNE- Multiple sclerosis
• IDIOPATHIC
• INFECTIONS- Meningitis
 PATHOLOGY
• Compression, laceration or bruising
of the brain inside the cranium/spinal
cord can lead to blood clot formation
inside the brain or formed outside or
beneath the dura mater (extra or
subdural haematoma)
• Infection eg in meningitis (oedema)
• swelling of the brain tissue following trauma is
also possible as fluid leaks from small blood
vessel spaces into the extravascular space
(brain edema)
• Once destroyed, neurons are not replaced. a
result this will cause neurological deficits
• Inactivity may lead to muscle atrophyand
weakness
• May present with loss of balance and
coordination
 PHYSIOTHERAPY TASKS:
ASSESSMENT
1. To record what the pt can do
2. To describe how he/she does it
3. To identify why the control of movt and
balance is disordered

 Consider what the pt does, or assessment of

his functional ability, including subjective
appraisal from the pt, relatives on how they
are coping in environment.
 CARDINAL SIGNS
The lesions of the corticospinal (pyramidal) tract
are:
1. Lack of control of movts (difficulty in initiating and
controlling movts and balance, impairments of balance reactions,
involuntary movts)
2. Increase in muscle tone (muscle tone may be increased or
decreased)
3. Hyperresponsive tendon reflexes (tendon reflex may be
hyporeflexive or hyperreflexive)
4. Extensor planter response (babinski’s sign)
 CLINICAL FEATURES
• Muscular weakness
• Muscle wasting and fasculation
• Muscle flaccidity
• Loss of tendon reflexes
• Spinal shock (Acute flaccid paralysis)
• Balance
• Inco-ordination
• Inco-ordination
• Cognitive functioning
• Aphasia
• Impaired sensation
• Bladder and bowel incontinence
• Positive Hoffmans(finger flexion reflex) and clonus
• Co-contraction- decreased rate of rapid alternating
movements between the agonist and antagonist across a
joint this and creates greater fatigability for voluntary
movements in weakened muscles.
 INSPECTIONS
OBSERVATION & PALPATION
Behaviour and orientation
• Dementia: inability to carry on normal intellectual and
mental functions, eg. Memory
• Cause: oxygen insufficiency in the brain resulting from
vitamin deficiency, toxins, infections, tumours,
inflammatory disorders, etc
• Pt with vascular or degenerative disorders like recurrent
CA and Parkinson's disease tend to be demented for
untreated causes
• Some times pt can not be aware of their environment or
may deny their illness
 Cont…..
Muscle tone
• this the elastic tension of muscles which varies
between rest and activity.
• Regulated by spinal reflex arc (afferent fibres from
receptors – spinal cord – efferent fibres return from anterior
horn [excitation is controlled by supraspinal centres] cells –
muscle)
• During stimulation, tone must be low enough to
permit movt but high enough to with stand gravity
• Abnormalities can be caused by dysfunction of
periphery or central pathways or supraspinal
centres.
 Cont…...
Spasticity
• It is a ‘release phenomenon’ caused by the release of
the antigravity mechanism of reticular form higher
control.
– Muscles stand out visible/tendons appear like cords
– Feel hard
– Resist stretch
– May increase with stretch applied then sudden collapse to
hypotonic state
– Its at lowest when pt is on side lying and increase as pt
becomes more erect
– Postural demands and anxiety can all increase hypertonus
levels
 Cont….
• Spasticity due to spinal cord lesions is similar in
that motor centres of spinal cord are released
from higher control but stretch tends to evoke
generalized movts of total flexion or extension of
lower limbs.
• Lesions of the cortispinal tract produces clonus,
evident in calf muscles when the ball of thefoot is
touched.
• It’s a manisfestation of hyperractive stretch reflex
which can be stopped by sustained dorsiflexion
 Cont….
Rigidity
• It is hypertonus due to loss of control of the basal
ganglia over the formation.
• Can be regularly or irregularly resistance to
passive movts (cogwheel rigidity) or
• Can be uniform through all parts of the range
with a plastic quality known as lead-pipe rigidity.
• Hysterical rigidity, resistance increases in
proportion to the force applied
 Cont….
Hypotonus
• Muscle hang away from the bone loosely; they
feel soft and flappy; lack resistance to strech;
unable to move the body or sustain posture
against gravity
• Due: acute insult to the brain, head injury or
surgery causing cerebral shock leading to less
responsive to stretch and lack of reinforcement of
cortical drive to initiate movt in muscle spindle
 Cont…..
Flaccidity
•Muscles hang away from the bone loosely and they
may appear small and atrophic; feel soft and flabby;
hyporeflexic and little or no resistance to passive
mvts.
•Limbs fall into abnormal positions but limited by
structures around joints
•Due: disruption of final common pathway in
anterior horn cell following spinal injury, infection
(poliomyelitis, syringomyelia or vascular occlusion)
 Cont…..
Posture
• Observe posture in supine, unless it is
contraindicated or prevented by another
condition,
• In sitting
• Standing
 GAIT
• Can the pt achieve a suitable starting position
in sitting from which he can stand up with
good posture alignment?
– Does he walk in a straight line?
– Does he swing his arms reciprocally?
– Can he stop and then start walking again?
– Can he turn and how does he do it?
– Can he negotiate obstacles
– Does he tend to fall, which direction?
 Hemiplegic gait
• The principal problem with hem pt is lack of
rotation:
– Both shoulder and pelvic girdle are retracted with
the trunk flexed forward to affected side
– Move side in one piece
– Affected lower limb likely rigidly extended in
order to bear weight.
– Upper limb doesn’t swing reciprocally
 Parkinsonian gait
• Have difficulty in rising from the chair
• Tend to lean backwards in standing
• Difficulty with balance, thus, compensate by flexing forward
• Take short, shuffling, rapidly accelerated steps – festinating
gait
• No trunk rotation
• No arm reciprocal swing
• Have difficulty to overcome inertia
• Respond to visual and auditory stimulus
• Difficulty in turning and changing direction
 Sensory ataxic gait
• Diminished proprioceptive sensitivity.
• Stand with wide base
• Raises the foot higher than necessary to clear the
ground
• Wobbles on standing leg
• Swings free leg forward jerkily
• May be fairly steady if he watches the ground; but
deteriorate his gait in dark
• Tends to stagger and make exaggerated movts with
upper limbs to maintain balance
 Cerebella ataxic gait
• Dysfunction of cerebellum interferes with
correlation of proprioceptive, visual and
vestibular sensations, thus fails to predict when
the foot will strike the ground or control and
coordinate patterns of voluntary movts and
balance reactions
• Swing their legs erratically
• Head and truck sway
• Arms may appear to be grabbing at thin air
• Reel from side to side drunkenly
 High step gait
• Pt with ‘foot droop’ due to palsy of
common peroneal nerve or anterior tibia
nerve
• Left their feet abnormally high in order to
avoid tripping over their own toes
 FUNCTIONAL ABILITY
• Ability to do everyday activities of daily living
must be assessed in home and work enviro.
The assessment may relate to
neurodevelopmental sequence
• Common functional mvts:
– Rolling
– Moving from lying to sitting on the side of bed
– Transferring from bed to chair
– Rising from sitting in a chair and sitting down
again
– Walking
 COMMUNICATION
• Communication may interfere with pt’s ability
to respond to treatment
• Could be truly deaf
• Have a hearing aid which he could not be
using
• Language problem
• Problem articulating words
 Dysphasia & Aphasia
• PT with right-sided hemiplegic may be unable to
comprehend speech and understand abstract concepts
• Bu capable of following simple questions and
commands
• May be unable to produce spontaneous speech; may
use neologism, or invented or nonsense words or use
descriptive phrase to replace name of object
• Pt may be unable to comprehend written words
• Lesions of dominant hemisphere may cause receptive
or expressive aphasia or global encompassing both
 Dysarthria
• Spastic dysarthria due to hypertonus of
muscle of speech, causing a drunken-
sound slurring of syllables
• Cerebella disease causes ataxia of these
muscles such that pt emphasizes every
syllable and speech loses its normal
rhythm
 MANAGEMENT
PHARMACOLOGIC MANAGEMENT: Common
oral medications
 (Muscle relaxants) include baclofen,
dantrolene, benzodiazepines, clonazepam etc.
Nerve blocks are another avenue of
treatment that can be of use in severe cases of
spasticity performed with fluoroscopy or nerve
stimulation as well as medicines.
Surgical Management
Its aims is to minimize neurological
deterioration, restore alignment and stabilization,
facilitate early mobilization, reduce pain,
minimize hospital stay and prevent secondary
complications.
Decompression of the spinal cord is suggested
in the setting of acute spinal cord injury with
progressive neurologic deterioration.
Tendon releases
Carotid endarterectomy – removal of
atherosclerotic plaque or thrombus from the
carotid artery to prevent stroke in pateients
with occlusive disease of the extra cranial
cerebral arteries
Hemicranietomy-performed for increased
intra cranial pressure from brain
edema/hematoma
CELLULAR THERAPY INTERVENTIONS
Though mostly in clinical trails but it shows to be the
future of intervention
Schwann Cell is one of the most widely used cell
types for the repair of the spinal cord.
Olfactory Escheating Cells are capable of
promoting axonal regeneration and remyelination
after injury.
Bone Marrow derived Mononuclear Cells (BM-
MNC’s) transplantation is feasible, safe and have a
good degree of outcome improvement. Stimulated
Macrophages invade the impaired tissue
NURSING CARE
Monitor the vitals and document them for the doctors
Hygience care- make sure the patients if they are in
the ward they are bathed
Check if the patients have bladder control or not
Make sure the medication is given on the proper times
Make sure the input and output of fluids is recorded
in the charts
Monitor the progress of the patients
Urinary catherther care and care of other intubation
Motor the feeding of the patient
Making sure the patients is turned hourly if
there is need
Positioning of the patients
Feeding the patients if they are feeding via
NGT tube
Education of the family on the care of the
patient
Alert other health care team members if the
patient is improving or not
 OCCUPATIONAL THERAPY
Will modify easier ways of doing activities of
daily living and other occupational needs that
may arise due to the injury
 SPEECH THERAPY
In case of speech problems are
speech therapist will help in
rehabilitating speech.
 ORTHOTICS
Making of braces, splitting's and
other orthotics the patient might need
to correct deformities
 NUTRITIONIST
• Teach the patient on the importance
of eating healthy foods that will
benefit the body
 PSYCHOLOGIST
Encourage the client to have a stress free
life by accepting the current condition
Refer to other social services that may
help in case of material help such as
necessities of daily living to other
relevant offices eg social welfare
Refer to other places- special school for
children with disabilities
 FAMILY
Emotional support
Helping the patients in doing most of activities
of daily living if the patient is unable to do a
particular ADL
Make sure the patient is feed, well looked after
in terms of personal hygiene of the patient
Exercises are done
Medication given to the patient
Turning of the patient every hour
Elevation of limbs
Patients is taken to hospital for
review and physiotherapy
treatment on the scheduled days.
PHYSIOTHERAPY MANAGEMENT
It the main stream in management of upper motor lesion
patient
Physiotherapy management is divided into three
stages
In the ward
Out patient
At home
Physiotherapy management in the ward
The management can either be in the ICU or the
general ward
ICU physiotherapy management
 PHYSIOTHERAPY IN ICU
 Respiratory physiotherapy
 Chest physiotherapy-breathing exercises percussion
and vibration
 Suctioning
 Postural drainage
 Muscoskeletal
 Passive movements of all the limbs
 Positioning-In anti spastic
 Positioning to avoid contracture formation
Positioning to avoid swelling eg position
the limbs where you elevate the limbs
Cushioning of pressure points to avoid
pressure sore formation
Hourly turning to change the pressure
points
Education to other members of the
health teach on the need to having high
hygienic stands
 GENERAL WARD
Chest physiotherapy eg breathing exercises
such as ballon blowing
Passive movts
Active assisted exercises
Strengthening exercises
Teaching of transfers in preparation for
ambulation
 PHYSIOTHERAPY DEPARTMENT
• On the bed
• Passive movement
• Active assisted execises
• Actives exercises
• Balance training
• Co-ordination exercises
• Strengthening exercises
• Teaching transfers in preparation for ambulation
 PHYSIOTHERAPY AT HOME
• Access the home environment
• Teach care givers the right exercises to be
done at home
• Education of change in life style change-
Importance of exercise
• Hourly turning
• Teach the care givers at home on the right
technique of lifting the patient
• Elevation of lower limbs and positioning