Motor dysfunction: motor unit

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Transcript of Motor dysfunction: motor unit

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Motor dysfunction: motor unit & myopathic disease

Learning objective

To understand and describe

• Myopathic and neurogenic disorders

• Four examples of motor dysfunction: Muscular dystrophy, Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis, Cerebral Palsy

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Motor dysfunction

Characteristic of the disease depends on the specific component of motor unit affected.

Different clinical implications for different sources of disease.

Myopathic: problems with the muscle

Neurogenic: problems with the motor neuron and ‘pre’-motor neuron

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Characteristics of the disease

Nerve cell body: motor unit disease (1)Motor neuron axon/neuromuscular junction: peripheral neuropathy (2&3)Muscle degeneration: myopathy (4)

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Neurogenic vs Myopathic diseases

Criteria for distinguishing neurogenic (cell body & axon) versus myopathic (muscle) diseases.Myopathic:

– main symptom: muscular weakness/wasting (atrophy)– leads to difficulty walking, lifting, etc.– also myotonia, myalgia, cramps

Neurogenic diseases:– have these characteristics also, but also ...– tendon reflexes lost– gradual weakening– fasciculations (visible muscle twitches)

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Upper and Lower motor neurons

Each produces distinctive symptoms

L o w e r m o to r n e u ro n

w ea kn e ss (L M N )

U p p e r m o to r n e uro n

w ea kn e ss (U M N )

F lac cid Spa stic ity

D e crea se d to ne In crea se d to ne

D e crea se d m us cle stre tch

refle xe s

In crea se d m u sc le s tretc h

refle xe s

P rofou nd m u scle a trop hy M inim a l m u scle a trop hy

F as cicu la tio ns pres en t F as cicu la tio ns ab se nt

M ay h av e s en so ry

d is tu rb a nce s

M ay h av e a ss oc iate d

se n sory d is turb an ce s

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Neurogenic vs Myopathic diseases

Normal muscle Denervated muscle Myopathy

Neurogenic and myopathic diseases have different effects on the motor unit.

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Neurogenic vs Myopathic diseases

Normal muscle Denervated muscle Myopathy

EMG activity during rest, slight contraction, and maximum contraction – to distinguish between neurogenic and myopathic diseases.

1 1

2 2

3 3

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Neurogenic vs Myopathic diseases

Biopsy results show histochemistry differences in the muscle fibres:

Type I and II fibres usually equal & distributed randomly

Neuropathy: can see size changes, clusteringMyopathy: can see damage

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Neuropathies: symptom mechanisms

Motor neuron disease: affects motor neurons leaving sensory neurons intact

Peripheral neuropathies affect sensory and motor functions

– often have paresthesias (numbness, tingling, etc)

May be categorized as ‘demyelinating’ or ‘axonal’

– demyelinating more common

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Demyelination

Record action potentials after simulating the motor nerve at two distances to determine conduction velocity.

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Demyelination

Leads to slowing of conduction velocity

In partially demyelinated nerve fibers, the action potentials propagate less efficiently.

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Demyelination

Nerves with different amounts of myelin (normal or partial) will conduct at different velocities, so lose synchrony of conduction.

Can lead to reflex problems and odd sensations.

insulation loss

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Demyelination: Causes

Viral: certain viruses can affect motor nerves selectively (e.g. poliomyelitus)

Neonatal hypoxia (e.g. cerebral palsy)

Genetic (e.g. muscular dystrophies)

Unknown (e.g., multiple sclerosis)

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Case 1: Duchenne Muscular Dystrophy

Description:

Genetic disorders characterized by progressive muscle wasting and weakness that begin with microscopic changes in the muscle.Shows signs of muscle weakness as early as age 3. The disease gradually weakens the skeletal or voluntary muscles, esp. those in the arms, legs and trunk. By the early teens, the heart and respiratory muscles may also be affected.

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Case 1: Duchenne Muscular Dystrophy

Symptoms (boys only)Children with the disorder are often late in learning to walk – clumsy, unsteady gait, difficulty raising arms, walk on toes– lose the ability to walk sometime between ages 7 & 12 – in teen years, activities involving the arms, legs or trunk require assistance or mechanical support

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Case 1: Duchenne Muscular Dystrophy

Muscle hypertrophy: enlarge muscles, esp the calf

– increases with age– most commonly due to

muscle fibrosis

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Causes of Duchenne Muscular Dystrophy

An absence of dystrophin, a protein that helps keep muscle cells intact.Dystrophin strengthens muscle cells by anchoring elements of the internal cytoskeleton to the surface membrane.

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Causes of Duchenne Muscular Dystrophy

Without it, the cell membrane becomes permeable, so that extracellular components enter the cell, increasing the internal pressure until the muscle cell "explodes" and dies.

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Case 2: Amyotrophic Lateral Sclerosis

Amyotrophic: neurogenic muscle atrophy, Lateral sclerosis: hardening of lateral corticospinal tracts

Description:

Upper and lower motor neuron disease

Motor neurons undergo shrinkage, caused by altered cytoskeleton

– they innervate less and less musculature, and those muscles atrophy

Mean onset age: 56-63

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Case 2: Amyotrophic Lateral Sclerosis

Symptoms:Initially, muscle weakness and stiffness Usually the first muscles affected are those in the hands, arms and legs. (lateral CS tracts)Speech problems, such as slurring, hoarseness, or decreased volume may also occur (dysarthria)

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Case 2: Amyotrophic Lateral Sclerosis

Symptoms:Motor neuron signs (normal sensation): atrophy, hyperactive MSR, hyper/hypotonia, Babinski’s sign, spasticity, fasciculations.Eventually, the ability of the brain to start and control voluntary movement is lost.

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Case 2: Amyotrophic Lateral Sclerosis

Causes:Exact causes of the neural degeneration is unknown 5 to10 % can be attributed to heredity

– there are multiple genes in which, if mutated, may cause ALS Suspects: viruses, neurotoxins , heavy metals, DNA defects (especially in familial ALS), immune system abnormalities, and enzyme abnormalities

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Case 2: Amyotrophic Lateral Sclerosis

Treatment:

Motor deficits only. Sensory and cognitive function intact

Treatment focuses on relieving symptoms and maintaining an optimal quality of life

Medications for spasticity, discomfort, pain

Physical therapy for cramping, contractures

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Case 3: Multiple Sclerosis

Description:

Myelin is lost in multiple areas, leaving scar tissue called sclerosis.

– damaged areas are also known as plaques or lesions

– sometimes the nerve fiber itself is damaged or broken

MS is a chronic, unpredictable neurological disease

The majority of people with MS don’t become severely disabled.

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Case 3: Multiple Sclerosis

Symptoms:

Wide range of unpredictable symptoms, vary from person to person, time to time

– can affect vision, speech, balance, bladder function, coordination

– may cause dizziness, pain, and tremors

Age onset: peaks between 20 & 30 years

Most people with MS are diagnosed between the ages of 20 and 50.

– Women twice as likely to get it

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Case 3: Multiple Sclerosis

Causes

It is believed that MS is an autoimmune disease – myelin is attacked.

Unknown what triggers the improper autoimmune reaction

Several factors are involved

Genetics

Gender

Environmental Triggers, possibilities include viruses, trauma, and heavy metals

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Case 3: Multiple Sclerosis

Treatment:

In the past, steriods have been used to reduce the duration and severity of attacks in some patients, or the symptoms such as spasticity.

Some of the FDA-approved drug treatments include:

Synthetic protein (Glatiramer Acetate or Copaxone) used to simulate myelin basic protein (acts as a decoy)

Mitoxantrone suppress attack (e.g. from T-cells) on the myelin sheath.

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Case 4: Cerebral Palsy

Description (not a disease, actually)

A non-progressive medical condition that affects control of the muscles, muscle tone

Cerebral means anything in the head and palsy refers to anything wrong with control of the muscles or joints in the body

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Case 4: Cerebral Palsy

Different types

Spastic (high tone), ~50%

Ataxic (low tone) ~25%

Athetoid (mixed tone) ~25%

Movement symptoms depend on type

– affects limbs, face, mouth, head

Learning disabilities in 25-50% of CP children

– slower rate of learning

Seizures in about 50% of children

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Case 4: Cerebral Palsy

CausesInjury to the brain before, during, or shortly after birth. In many cases, not sure what caused the brain injury or what could have prevented the injury. - Neonatal/perinatal: insufficient oxygen (hypoxia) and/or insufficient blood (ischemia) is a major cause of damage to the newborn infant’s brain- Prenatal: maternal infection or accident, maternal medical condition such as high blood pressure or diabetes

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Case 4: Cerebral Palsy

TreatmentsExercise and it’s favourable impact factors

Cardio-pulmonary condition-ing, muscle strength building and coordination.

TherapiesPhysical, recreational,

speech, occupationalAdapted objects, communication & mobility aids