4 4 Chapter 1 Motor Behavior of Adult Patients with Hemiplegia Persons with lesions affecting certain portions of the vascular system of the brain—mainly the areas supplied by the midalle cerebral artery — exhibit motor disturbances in one half of the body; helice, the disability is referred to as hemiplegia or hemiparesis. Sensory disturbances are frequently, although not universally, present; like the motor disturbances, the sensory deficits appear in the body half that is opposite the brain lesion. The largest number of patients with hemiplegia Seen in a rehabilitation clinic are the “stroke patients” who have suffered cerebral vascular ac- cidents as a result of thrombosis, hemorrhage, embolus, or aneurysm. Hemiplegia may also’ be of traumatic origin or may be caused by a neoplasm. The degree of involvement as well isthe differential diagnosis vary greatly among patients with hemiplegia; yet numerous como: characteristics may be observed, and some of these will presently be discussed. These common characteristics, however, do not exclude in- dividual differences among patients because no two patients are exactly alike. THE BASIC LIMB SYNERGIES . Normal movement is characterized by synergistic motor behavior, that is, the coupling together of muscles in an orderly fashioW- asa means by which purposeful movement is achieved with maximal precision and Jsinimal f energy. Purposeful movement accomplishes what it intends to accomplish, and, while some stereotyping occurs, the ability to use different combinat tions of muscles in varying degrees of intensity of movement is almost limitless. Some stereotyping occurs in normal movement patterns; for example, an individual's walking pattern and writing pattern, once well established, do not change over time and easily distinguish that individual's walking and writing from those of other individuals.10. Motor Behavior ot At Pats wth Hecrplegia In contrast to normal synergistic movement Patterns, the basic limb seed oth in ineividuals who have sustained » cervtear vascular accident are almost entirely stereotyped and sto mat permit different smmbinations of muscles. The group of muscles consis twlinga hemiplegic limb synergy acts together as a bound unit af motion and, in the Stages of recovery following a early cbral vascular accident, produces the The resale resPestive ofthe patient's attempt to vary the outcome. The resulting movements, whether evoked volitionally or reflexly, are Primitive, automatic, reflexive, highly similar among all patients with hemiplegia, and reflect the loss of inhibitory control normally exerted by the higher centers of central nervous system integration 18 most patients thie accidity that follows the acule episode is sooner” or later replaced by spasticity. It is dluring the early spastic period that the hemiplegic limb synergies make the. appearance, either as reflex TesPonses or as voluntary movements, or beth They consist either of a Bross flexor movement (flexor synergy) or » Bross extensor movement (extensor synergy). Variations do occas, but these are related mainly to the relative strength of the individwal synergy components and do not indicate a change in the nature of the Synergies. Neurophysiologically, the muscles that are activated in a synergy are firmly linked together, A Patient with hemiplegia is unable to recut these same muscles for different movement combinations and cannat maste: Plantar flexion of the toes (inconsistent, great toe'may extend) The extension synergy typically dominates in the lower extremity with considerable hip adduction, knee extension, and ankle plantar flexion appearing. The synergy can almost always be initiated HrGUghractivation Of itS "Strongest component, knee extension (The quadriceps tend to be Wst Spastic component, but itis theacaictor muscles that, stronglylinked to the quadriceps in synergy, interfere greatly with performance of upright activities. ) This synergy evoked as an associated re tion is scen in Figure 1-4, Because hip and knee were already extended, the synergy manifested itself as plantar flexion of the ankle with inversion, tensing of the quadriceps muscles, and adduction and internal rotation of the hip. Reversal of Movement Directions ‘The joint movements of the extensor synergy occur in the opposite direction from those of the flexor synergy. This reversal of moverhent directions is true not only for flexor and extensor components but also for the other components. (Abduction and external rotation at shoulder and hip accompany the flexor synergies, adduction and internal rotation. the extensor synergies Dorsiflexion of the ankle is an integral part of the flexor synergy, plantar flexion of the extensor synergy. But inversion of the ankle accompanies both the flexor and the extensor synergies Eversion of the ankle has never been seen by the synergy. authors in either __The Basic Limb Sy 15,Hier OF Alt Patients swith Hemiptega in the upper limb, extension of the wrist may be considered.a component of the extensor synergy and flexion of the wrist » component of the flexor synergy, but variations do occur and are discussed Intex Interaction of Synergy Components The quantity as well as quality of motion whose movements are dominated by the much influenced by the relative'stiength of i and the manner in which componer opposing movements, interaction in the its character. among hemiplegic patients basic limb synergies are very individual synergy components nts interact in complimentary and Section illustrates typical examples of that Production of synergy movement and helps to explain upreR ume th ns been noted previously that elbow flexion, shoulder adduction with internal rotation, and forearm pronatio ate the domicaat, Frcnts of the upper extremity flexor and extensor synergies, respectively. When flacidity subsides fllowing.a cerebral vascular acetone and spas- [Sty begins to develop, these components are also the first to display tone and the first to respond to voluntary effort Early attempts at move- Matin a Mexor direction, for example, may result only in elbow fanny through an incomplete range. Similaly, early attempts at movement in su extensor direction may result only in ae movement pattern Abduction and exte often weak components of the flexor synergy, and, although they may pepear (nore strongly later in the recovery period, some patient may never achieve full range of abduction and external rotation), AS spasticity continues to develop in the early recovery stages and SYnErBY Movement becomes mote pronounced, the interaction of ‘opposing, ese Ry Somponents becomes more evident. Components that hove bace described as weak are in fact often capable of activation butare inhibited by the dominance of their antag, ts. Since, neurophysiologically, stretch acts as a primary stimulus for Contr: \, and since contraction of a miscle inhibi oF _Contzaction, lis.anlagonist, the “weakness” of the elbow svtekoh, ance at the extensor: synergy may actually be inhibition astic: SALGORIstic elbow flexors during. the attempted movement. If the elbow flexors; Which are more than normally Sensitive to stretch because of spasticity, respond to the stretch stimulus by contracting, the elbow extensors become inhibited. Thus, the range Of slbow extension seen in the extensor synergy ig incomplete. nmJ Similarly, the often spastic pronator group will frequently preclude complete supination of the forearm. Neurophysiologically, there is a close link between the flexor muscles of the elbow and the supinators of the forearm; hence, the movement of flexion of the elbow and supination of the forearm tend to occur together during performance, either voli tionally or reflexly, of the flexor synergy. If pronator spasticity is marked, however, which is frequently the case when the hemiparetic condition is of longer standing, the forearm may remain pronated during per- formance of the flexor synergy.) This interaction of opposing Synergy components should be considered when evaluating any synergy movement. In general, it can be stated. that the antagonists of the dominant components of one synergy will be the weakest components of the other synergy. Thus, since the shoulder adductor and internal_rotators, primarily pectoralis major, are often markedly spastic, shoulder abduction and external rotation are difficult to achieve in the flexor’ synergy. Passive range limitations in-spastic muscle groups must algo not be ignored TYPICAL ARM POSTURE In patients who exhibit marked spasticity in the upper limb, the in- voluntary arm posture seen in Figure 1-5 is commonly observed in erect igure 1-5 posture.1B Motor Behavior of Adult Pate with Seniples standing and walking. Because of the frequency with which this arm Posture is seen among, patients with henipley called th !vpivalarm posture in hemiptesia.”"This atti the strong eTponent of the Hesor syne it has been combi (elbow Hexion) with the two strongest components of the extensor synergy (pronation of the forearm, addiichon nthe shoulder). It shout be stessed that the typical arm posture i ‘voluntary; thal is, patients whose arm movements aie strongly dom, inated by synergy will be unable to assume the arm posture voluntarily, since attempts at elbow flexion will activate the remaining, flexor com. ponents (.e., shouldér abduction with external wolation, oF hyperexten sion). J Uh the arm posture described, some spasticity is likely to be present in the triceps muscles, but the elbow flexors, which in the erect position are antigravity muscles, have far more tension; flexed. When initiation of elbow extension first succeeds, it dees an only in conjunction with the other two extensor components hence the elbow remains LOweR ume Many hemiplegic patients fail to achieve hip abduction and the attendant Stability that is necessary for standing balance and ambulation. This is caused, at least in part, by the fact that neither of the basic lower extremity (ee har as the components required for adequate stance and walking (see Chapter 4). It is also caused, at least in part, by the interaction wainteecomPonents. Weight bearing on the affected limb markedly reinforces the extensor synergy, especially its strong components, It was Previously noted that the knee extensors are the most dominant sad the aeaaie Component of the extensor synergy, followed closely by the hip adductors. In severely involved patients, the adductor component Bay be so prominent that the affected limb crosses in front ofthe unwifectedt between opposing synergy components limb. In any event, the interaction asa bound unit of motion, the adductor ‘0 the contraction of the quadriceps; con- scdtently, the abductor muscles become inhibited. Efforts at abvivction Seem only to aggravate and further enhance adduction, Possibly because ‘hese elforts serve as a stretch stimulus to the adductor muscles ‘Another example of the interaction among synergy components is sh nhich exists between the hip flexors and the ankle dorsiflexor: nin the flexor synergy. Once activated with hip flexion, the ankle e Mexor synergy. Once activated with hip flexion, the ankl muscles contract in response t th2 Atitudinal or Postural Reflexes dorsiflexors may have great strength if tested against resistance. Never-, theless, the ankle muscles seldom, if ever, are seen to initiate the flexor’ synergy; their activity appears to be evoked by stimuli originating in the hip flexor muscles, In addition, independent (j.e., isolated) activation + of the ankle dorsiflexors occurs only much later in the recovery process 3 when the synergies have lost their dominance over volitional activi = ATTITUDINAL OR POSTURAL REFLEXES Tonic Neck and Labyrinthine Reflexes \c moos | KV Ce The tonic neck and labyrinthine reflexes are known as “Magnus’s and p de Kleijn’s reflexes” after two Dutch scientists who discovered the rules that govern these phenomena (Magnus and de Kleijn, 1912). The most convincing experiments of these investigators were conducted on de- ____. cerebrate animals because in such preparations no voluntary impulses disturb the reactions; but the presence of these reflexes also in intact animals was established without a doubt. ‘The tonic neck reflexes are evoked by neck movements or neck positions; they are either symmetrical, as in flexion and extension of the neck, or asymmetrical, as in rotation or side-bending of the head and neck. The symmetrical neck reflexes act identically on the limbs on the left and on the right sides; the asymmetrical neck reflexes have opposite effects on the left and on the right limbs. In each case, proprioceptive impulses . originating in the cervical region affect the reflex centers in a predictable” 7” manner, as discovered by Magnus and de Klejjn. quec climes reo i a SYMMETRICAL NECK REFLEXES In animals, ventroflexion of the neck results in flexion of both forelimbs and extension of both hindlimbs; dorsiflexion of the neck has the opposite ct, that is, extension of both forelimbs and flexion of both hindlimbs. fre: two attitudes may be visualized by analyzing the events that take Place when a quadruped animal creeps under a fence. First, the head is lowered and the forelimbs flex, while the hindlimbs are still extended; then, as the animal moves forward, the head is raised and the forelimbs extend; at this time, the hindlimbs flex to permit the hind part of the body to follow. ASYMMETRICAL NECK RLFLEXES The asymmetrical neck reflexes are governed by “flexion of the skull limbs” and “extension of the jaw limbs.” When the jaw of the animal is rotated to the left, the left limbs become the “jaw limb3” and exterid; the right limbs become the “skull limbs” and flex. The facilitatory effect