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Upper motor neuron lesion

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Axons, Muscle relaxant, Noradrenergic, Acetylcholine, Neuromuscular, Parasympathetic, Pudendal, Adrenergic, Alpha-adrenergic,
Cervical myelopathy

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Electrodiagnostic Findings in Physical Examination of the Wrist and

Neuromuscular Disorders Hand
Bashar Katirji, in Electromyography in Clinical Practice (Second William A Mitchell, Ahmed A Radwan, in The Sports Medicine
Edition), 2007. Resource Manual, 2008.

UPPER MOTOR NEURON LESIONS Upper motor neuron lesion

Patients with upper motor neuron lesions have normal NCSs and
needle EMG including normal insertional activity, no spontaneous
activity at rest, and normal MUAP morphology. The only abnormality
is a reduced interference pattern with poor activation of MUAPs (slow
rate of motor unit discharge). Recruitment, measured by either
recruitment frequency or ratio, is normal. Hysterical weakness or
poor effort produces a similar pattern, except that motor unit firing
may be irregular.
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Hoffman’s sign
This test will indicate the presence of an upper motor neuron
it is considered the upper extremity equivalent of the Babinsk
The examiner holds the patient’s middle finger and flicks the d
phalanx briskly. The test is positive if the thumb IP joint on the
hand flexes. Because upper motor neuron lesions will affect th
upper and lower extremities, a positive test should prompt the
examiner to also check for Babinski’s sign and clonus in the fe
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Physical Examination of the Cervical and

Thoracic Spine
Physical Examination of the Lumbar Sp
Derek A Woessner, Charles W Webb, in The Sports Medicine
Resource Manual, 2008. Philip Ham, James D Leiber, in The Sports Medicine Resource
Manual, 2008.

Special tests
Babinski's test
Hoffman's sign This test is used to evaluate for an upper motor neuron
the patient sitting, the physician slides a fingernail down the p
Hoffman's sign tests for upper motor neuron lesions above lower
surface of the patient’s foot. This should make the big toe flex
cervical spinal cord levels. When flicking the tip of the middle finger
big toe extends and the other toes abduct, then the test is pos
with the hand in a relaxed neutral position, the examiner will note a
positive finding with the flexion of the thumb and index finger
together in a pincer motion (Figure 10.3). ˃ Read full chapter

Spurling's sign

Spurling's sign involves pain radiating to the upper extremities after

applying gentle, firm pressure to the patient's head with the head
rotated and extended (Figure 10.4). This is often used to diagnose
radicular pain syndrome. The sensitivity of Spurling's sign is 0.30 to
0.50, with a specificity of 0.74 to 0.937,8 (LOE: D).
A 22-year-old Male Farmer from Rural
Ethiopia with Difficulty Walking
Abduction relief sign (Bakody's sign)
Yohannes W. Woldeamanuel, in Clinical Cases in Tropical Med
2015.
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When disc protrusion is suspected as the cause of radicular pain, Answer to Question 1
Bakody's sign is performed by having the patient place the hand of
the affected upper extremity on the head. Arm abduction reduces What Clinical Syndrome Can You Apply for a Diagn
symptoms by taking stretching pressures off of the affected nerve Approach and How Do You Narrow Down Possible
root. In a case series by Viikari-Juntura and colleagues,9 this Differential Diagnoses?
maneuver was discovered to have a sensitivity of 0.31 to 0.42 and a
specificity of 1.0 (LOE: D) (Figure 10.5). Upper motor neuron lesion with spastic paraparesis is the clin
syndrome. Absence of radicular symptoms, sensory level, sphi
Bikele's sign disturbance, back pain, non-progression, HIV-seronegativity a
negative family history rule out most compressive, hereditary,
Bikele's sign occurs when a sitting patient is asked to raise the infectious and metabolic myelopathies.
involved arm laterally into a horizontal, slightly backward positi… ␡
Among tropical myelopathies, HTLV-associated myelopathy
highly unlikely. HAM has usually an insidious onset and a slow
progressive course, bladder impairment and sensory symptom
prominent. Neurocassavism (konzo) may also present with a s
onset spastic paraparesis but is improbable in the absence of
Figure 10.3 Figure 10.4 Figure 10.5
Hoffman's sign. The For Spurling's sign, the Disc protrusion causing
exposure. Male gender, pre-onset physical exertion, excessive
patient's hand is in a
relaxed, neutral position,
examiner applies gentle,
firm pressure to patient's
radicular pain can be
tested with the abduction
prolonged guaya consumption and history of similarly affecte
and the examiner flicks head with the head relief sign. The patient members favour a distinct form of toxiconutritional disease ca
neurolathyrism.
Figure 10.7
˃patient
In the second part of Bikele's sign, the Read full chapter
is asked to flex the elbow
while laterally flexing the neck to the opposite side. Active extension of
Figure 10.6 Figure 10.7 Figure 10.8
the elbow, which causes the brachial plexus to stretch, produces
Bikele's sign tests for In the second part of Lhermitte's sign indicates
nerve root inflammation. Bikele's sign, the patient resistance
irritation of the spinaland
increased cervicothoracic radicular pain.
The sitting patient is is asked to flex the elbow dura mater by a
asked to raise the while laterally flexing the protruding cervical disc, a

Figure 10.10
Hautant's test identifies
Figure 10.9 insufficient blood flow
through one or both
The Soto–Hall test. vertebral arteries. The test
Rehabilitation of Neurologic Disability
Figure 10.11
In the Sharp−Purser test,
Mel B. Glenn, Susan Biener Bergman, in Office Practice of
the sagittal stability of the
atlantoaxial segment is
Neurology (Second Edition), 2003.
assessed. The patient is

˃ Read full chapter BOWEL DYSFUNCTION

Cervical Spine Rehabilitation
Todd R. Hooks, in Physical Rehabilitation of the Injured Athlete
(Fourth Edition), 2012.
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Brain Stem Disease
Eugene C. Lai, in Neurology Secrets (Fifth Edition), 2010.
What is pseudobulbar palsy?
Pseudobulbar palsy is a syndrome of upper motor neuron paralysis
that affects the corticobulbar system above the brain stem bilaterally.
Although it presents with most of the signs and symptoms of bulbar
palsy, the causative lesion is not in the brain stem. This condition
causes dysphagia, dysarthria, and paresis of the tongue (without
atrophy or fasciculations). In contrast to bulbar palsy, the reflex
movements of the soft palate and pharynx are frequently hyperactive.
The jaw jerk is brisk. Frontal signs (grasp, snout, suck, and glabellar
reflex) may be present. Emotional incontinence with exaggerated
crying (or, less often, laughing) is also common and may be due to
disruption of frontal efferents subserving emotional expression.
Multiple lacunar infarcts or chronic ischemia in the hemispheres
Patients with lower and upper motor neuron lesions may expe
constipation and bowel incontinence. A regular bowel program
usually can minimize these problems. After adequately empty
constipated gastrointestinal tract with laxatives and enemas
necessary, a regular daily or every-other-day suppository or di
stimulation combined with a fiber-rich diet and plenty of fluid
good starting point. If this is unsuccessful, a stool softener—o
stool needs added bulk, psyllium hydrophilic mucilloid—can b
added. A laxative such as senna can be given, timed so that its
coincides with the administration of the suppository or digital
stimulation. Glycerin suppositories may suffice for some, whe
bisacodyl suppositories or minienemas may be needed for oth
Attention should be paid to the bathroom equipment used by
patient to be sure that it fits correctly, is stable, and does not p
much pressure on the skin.
If treatment proves difficult, rectodynamic studies, if available
used to identify anorectal dyssynergia, which can be treated w
topical viscous lidocaine or prolonged anal stretch. If megarec
diagnosed, high-volume enemas may be necessary. Colostom
should be reserved for those for whom all other approaches h
failed.
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affecting bilateral corticobulbar fibers usually cause this syndrome.
Other causes are ALS and multiple sclerosis.
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Examination of the Motor System:
Approach to Weakness and Tremor
in Evidence-Based Physical Diagnosis (Second Edition), 2007.
INCREASED MUSCLE TONE
Spasticity
Definition
Spasticity is increased muscle tone that develops in patients with
upper motor neuron lesions.19–22 The increased muscle tone of
spasticity has three characteristic features: (1) Velocity-dependence.
The amount of muscle tone depends on the velocity of movement.
There is more resistance with rapid movements and less resistance
with slow ones. (2) Flexor and extensor tone differ. The tone in the
flexors and extensors of a limb is not balanced, which commonly
causes characteristic resting postures of that limb (see later). (3)
Associated weakness. The muscle with spasticity is also weak. In
addition, muscles shortened by spasticity eventually develop fixed
contractures, unless the spasticity is treated.
Characteristic Postures
In spasticity, an imbalance in flexor and extensor tone commonly
causes abnormal postures of the resting limb. In hemiplegia, for
example, there is excess tone in the flexors of the arms and extensors
of the legs, which causes the arm and hand to be fixed against the
chest, flexed and internally rotated, and the leg to extend with the
foot pointed (see Fig. 5-4 in Chapter 5).23 In contrast, some patients
with complete spinal cord lesions have excess tone in the flexors of
the legs, which causes the legs to flex up on to the abdomen
(“paraplegia-in-flexion”). *2024
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Pulmonary Manifestations of
Neuromuscular Diseases
John R. Bach, in Pulmonary Manifestations of Pediatric Diseas
2009.
Neurologic versus Muscular Disease
Some neuromuscular diseases include upper motor neuron
involvement. Upper motor neuron lesions result from patholo
the cerebral cortex, brainstem, or spinal cord and are signaled
increase in muscle tone (spasticity), hyperreflexia, and the pers
or reappearance of primitive reflexes, such as the extensor pla
response (Babinski sign). These patients also may have reflex d
breaths (“sighs”) and coughs despite having very low vital capa
and PCFs. Lesions above the foramen magnum also may prod
contralateral hemiplegia. Lesions in the cortex or subcortical a
often are associated with disorders of speech or other cortical
functions. Lesions in the brainstem usually affect cranial nerve
function ipsilateral to the lesion and contralateral hemiplegia.
Abnormalities in the spinal cord typically cause bilateral weakn
because of the close proximity of the descending tracts. Upper
neuron disorders can be identified and differentiated further b
imaging studies such as computed tomography, magnetic res
imaging, and myelography.
The lower motor neuron system includes the anterior horn ce
peripheral nerve, the neuromuscular junction, and muscle.
Manifestations of lower motor neuron involvement include
depressed reflexes, fasciculations, and muscle atrophy. Anterio
cell diseases cause distal weakness without sensory symptoms
whereas disorders of peripheral nerves are almost always
accompanied by sensory loss secondary to the involvement of
nerves, hyporeflexia, and usually distal weakness. Peripheral n
weakness can result from damage to either the core axon
neuropathies) or the myelin sheath that coats the nerve
(demyelinating neuropathies). Disorders of the neuromu…
˃ Read full chapter
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