Week 7 – Normal movement and movement disorders

Movement and our muscles

All movement depends on muscle contraction, even movement that we cannot

control consciously.

Skeletal muscle:
- Controlled by somatic nervous system and is generally under conscious
control.
- Can contract independently

Smooth muscles:
- Muscles are under the control of the autonomic nervous system
- E.g., bowel muscle = eat food, chew food, swallow (you don’t sense the
smooth muscle contractions as it goes down to the stomach).

Cardiac or heart muscles:

- Not under voluntary control but rather control of the autonomic nervous
system
- Still able to sense the beating of the cardiac muscles

Motor Unit:
- Is one motor neuron in the anterior horn of the spinal cord (upper motor
neuron)
- All muscle fibres are innervated by the branches of the axon.

Skeletal muscle
- Within the muscle fibres are myofibrils
- Within the myofibrils there are actin and myosin, the contractile elements
of the muscle fibres.
- Actin and myosin are both proteins that act together to allow a muscle to
contract.
- Myosin forms thick filaments within the muscle fibres, while actin forms
thin fibres.
Background tone
- Except during certain stages of sleep, most of our muscles are in a state of
slight contraction = known as muscle tone
o E.g., sitting up = neck muscles keep your head up/back muscles
keep your back up etc.
- Important function of muscle tone for human beings = helps us to
maintain an upright posture (background tone).

Hypertonia = (high level of muscle tone)

Hypotonia = (low level of muscle tone)

Antagonist and agonist muscles

- Muscle fibres are attached to bone by bundles

of collagen fibres known as tendons.
- When the neurotransmitter acetylcholine is
absent, the muscle relaxed
- All muscles work in pairs… when you bring
your hand to your mount, biceps are the prime
mover or agonist, while triceps are the antagonist.
- Agonists tend to shorten, while antagonists tend to relax however they
can switch roles.

Types of muscle work

Isotonic (same length)

- Concentric contraction (isotonic shortening)
- Eccentric contraction (isotonic lengthening)
- Isometric (isotonic contraction)
Isotonic concentric and eccentric is where the length of muscle shortens or
lengthens although tone/tightness remains constant.

Isometric is where the joint does not move, and the muscle maintains the same
length.

Sensory feedback and movement

To execute movement fluidly we rely on multiple systems.

Visual system:
- detects features in the environment
- maintains stable gaze when head moves
- recognises objects to be manipulated
- assists maintenance of balance of the body

Vestibular system:
- monitors head position in space (in relation to horizon)
- co-ordinates head & body movements to keep body
balanced
- stabilizes the gaze when head is moving

Somatosensory system:
- proprioception (receptors in muscles & joints)
- nociception (pain, receptors in skin)
- temperature sense (hot/cold, receptors in skin)
- texture discrimination (detect slip, receptors in skin)
- grip force required (touch discrimination)

Motor control:

Depends on interactions between the individual, the task and the environment
(these key elements be familiar from OT model).

Environment:
- Sensory perception
o Essential to give us information from our bodies, and the
environment for movement
o Involves primary reception of sensory stimuli, and perceptual
processing which attaches meaning to the primary sensations.
 - Vestibular system
o Head and neck position in relation to horizon.
- Muscle proprioceptors
o Information re: position of body in space.

Individual:
- There are cognitive and perceptual aspects within the individual
- Perceptual skill of interpreting sensory impressions into meaningful
information
- Cognitive skill of executive decision making is important
- Memory for learnt skilled movements is another cognitive skill required
for movement
- Attention, motivation, emotional aspects associated with movements can
affect their quality too.

Task:
- Variables that are inherent within the task, e.g., movement requirements
for the task are altered by such variables as size of object, density and
weight of materials.
- Understanding of task attributes to providing a framework for structuring
tasks.

Somatosensory System:

Muscle proprioceptors

- The nerve endings that relay all the information about the
musculoskeletal system to the central nervous system are called
proprioceptors.
- Proprioceptors are the source of knowledge regarding one's own body
position and movement. The muscle proprioceptors work at a reflex level.
- The proprioceptors detect any changes in physical displacement
(movement or position) and any changes in tension, or force, within the
muscles of the body. Muscle Proprioceptors regulate the contraction of a
muscle.
- Muscle spindles are the proprioceptors found in the muscle and react to
muscle length & rate of muscle stretch (ie. velocity).
 - Another proprioceptor that comes into play during stretching is located in
the tendon near the end of the muscle fibre and is called the Golgi tendon
organ. These sense muscle tension and detect fatigue in the muscle
- So the proprioceptors are sensitive to the position or movement of any
part of the body.
- The proprioceptive system is a feedback/feedforward loop operating in
the brain.
- The proprioceptive system gives feedback on movements being
performed but also has a role in preparing for movements before they are
initiated. That role is called feedforward.
- The cerebellum is the structure in the brain that has a major role in
modifying movement

Muscle Spindles:

- Spindle shaped sensory receptors.

- Collection of intrafusal muscle fibres (very small).
- Sits within the bulk of the extrafusal muscle fibres.
- Sensitive to muscle stretch & velocity of stretch.
- Resists passive stretch caused by gravity.
- Provides position in space information to the somatosensory system
- Facilitates the agonist (prime mover) & the synergists to contract &
inhibits contraction of the antagonists (reflex actions).
Muscle spindle in action:
- When the muscle is stretched, so is
muscle spindle.
- If above threshold, this triggers the
stretch reflex which attempts to resist
the change in muscle length by
causing the stretched muscle to
contract.
- The more sudden the change in
muscle length, the stronger the muscle contractions will be.
- Helps to maintain muscle tone and protect the body from injury.

Golgi tendon organs:

- Sensitive to muscle contraction and the force of contraction

- Golgi tendon organs acts as a brake or shock absorber to prevent
contractions that are too quick or extreme.
- Golgi tendon organs sense an increase in
muscle tension
- Provides position in space information to
somatosensory system
- Inhibits the agonist (prime mover) and
synergist/s and facilitates contraction of the
antagonist, thus modifying or reducing the
force of the contraction.

Golgi tendon organs in action:

- When muscles contract – produce tension where muscle is connection to
tendon.
- Tendon records the change in tension/rate of change in tension and can
send signals to the spine to convey information.
- When tension exceeds certain threshold, it triggers reflex inhibiting
contractions and causes it and any synergists to relax.
Voluntary and involuntary movements

- Involuntary movements
 - Most primitive reflexes disappear as our nervous systems mature
- Allied reflexes are strong in infants and usually persist into adulthood,
e.g. sneezing with dust or closing eyes in strong sunlight.

The asymmetrical tonic neck reflex occurs when a baby’s head is turned. The
arm and leg of the face side extend and the arm and leg of the skull side flex.
The asymmetrical tonic neck reflex disappears around 6 months of age.
Infants with cerebral palsy = reflexes do not disappear, so imagine how hard it
is for a child trying to learn to feed itself if the ATNR keeps kicking in!
Following brain damage = primitive reflexes can re-emerge

Sensitivity to feedback

Ballistic movements
- Movements from reflex activity (withdrawal reflex)
- Can’t be altered
- Not sensitive to feedback (e.g. knee jerk reflex)

Voluntary movements
- Movements under voluntary control
- Guided movement used in therapy
- Sensitive to feedback & therapy interventions

Movement sequences

Central pattern generators

- Neural mechanisms that generate rhythmic patterns, e.g. walking in
humans, dog shaking water off coat
- Generated at a spinal cord level
- Interneurones involved

Motor program
- Fixed sequence of movements (e.g., tenodesis grip)
Upper motor neuron lesion (UMN)
UMN Lesions cause changes in motor control and these are commonly termed
the "upper motor neuron syndrome". Affected muscles typically show multiple
signs, with severity depending on the degree of damage and other factors that
influence motor control.

- Muscle weakness (decreased ability for the muscle to generate force).

Often accompanied by spasticity (hypertonia).

- Spasticity = exaggerated stretch reflex, meaning ta muscle has a reflex

contraction when stretched, and that this contraction is stronger when the
stretch is applied more quickly.

- Decreased motor control including decreased speed, accuracy and

dexterity

- Altered muscle tone (hypotonia or hypertonia) – a decrease or increase

in the baseline level of muscle activity

- Exaggerated deep tendon reflexes including spasticity and clonus (a

series of involuntary rapid muscle contractions)

Lower motor neuron lesion (LMN)

A lower motor neuron lesion affects nerve fibres traveling from the ventral horn
of the spinal cord to the relevant muscle or muscles, ie. the lower motor neuron.
LMN Lesions cause changes in motor control such as:

- Muscle weakness/paralysis – paralysis accompanied by loss of muscle

tone (flaccidity).

- Hypotonia or atonia - tone is not velocity dependent.

- Decreased muscle strength – weakness is limited to segmental pattern

(only muscles innervated by the damaged nerves will be symptomatic).

- Hyporeflexia or areflexia - deep reflexes even cutaneous reflexes are also

decreased or absent
 - Muscle wasting over time.

Motor areas and movement initiation

- Primary motor area: generates motor commands. It relies on

feedforward information and feedback information.

- Premotor Area: planning/preparation of movement. Integrates

information from the visual area or information from the pre-frontal area,
& then communicates with the primary motor area in the planning of
movement.

- Supplementary Motor Area: Plans complex voluntary movement &

integrates bilateral movement & links with the primary motor area e.g.
rapid series of movement

- Primary Motor Cortex: generates or initiates commands

- Cerebellum: provides a great deal of feedback on movement & posture

- Basal Ganglia: When sequences of movement are involved, which is

most movement, the basal ganglia has a major role in the overall control
of sequences of
movement & initiation of
movement.

Corticospinal tract: motor pathways

Lateral corticospinal pathways (pyramidal tract)

- From motor cortex to contralateral muscles

- Control’s neck/shoulder muscles and precise movements of the distal
musculature of upper extremity.
- Lateral corticospinal axons/tracts cross at the caudal end of the medulla

Ventral (anterior) corticospinal pathways

- From motor cortex to ipsilateral and contralateral muscles

- Controls proximal movements of the head, neck and trunk (axial muscles)
- Ventral corticospinal pathways cross the midline close to the trunk
muscles

Somatosensory cortex and movement

Primary somatosensory area = receives stimuli from environment

Temporal lobe = processes vestibular information and processes sounds from

the environment.

Striate area/occipital lobe = processes visual information from retina of the

eyes

Posterior parietal cortex = processes sensory information, interprets position

of body relative to the environment or the horizon.

Basal ganglia/movement

Basal ganglia: a group of large sub-

cortical structures in the forebrain.

Responsible for:
 - Planning
- Initiating Of skilled movement that are mostly autonomic
- Regulation

Also crucial for overall control of sequences of all movements

- Substantia nigra,
- Sub-thalamic nucleus,
- Caudate nucleus,
- Globus pallidus &
- Putamen

Role of basal ganglia

- Selecting & maintaining

purposeful motor activity while
suppressing useless movements.

- Monitoring & coordinating

slow, sustained contractions.

- Learning motor skills: rules for

movement.

- Stereotypic movement: learned

while nervous system is developing, e.g. arm swing when walking.

- Organizing sequences of movements into smooth, automatic wholes.

- Automated movements: facilitates learning of movements that once

learned become automatic, e.g. driving a car.

- Inhibiting muscle tone throughout body.

Damage to the basal ganglia:

- Damage to different parts of this area causes difficulties in planning and

performing movements.

- Difficulties initiating, continuing or stopping movements. (Parkinson’s

disease)

- Problems with muscle tone: rigidity.

 - Resting tremor (Parkinson’s disease

- Increased involuntary, undesired movements: tremor, chorea, athetosis.

(Huntington’s Disease)

Cerebellum/movement

- Balance and coordination = maintain posture/equilibrium

- Important for motor control
- Refines newly learnt motor programs and skills
- Role in guiding/monitoring movement, not initiating movement.

Damage to the cerebellum:

- Ataxia: uncoordinated gait or UL movements.

- Dysmetria: inability to judge distances.
- Dysdiadochokinesia: inability to rapidly change movements (eg.
pronation/supination).

- Dysynergia: movements are no longer smooth & co-ordinated, more a

sequence of separate movements.

- Staccato voice: i.e. broken speech, not smooth.

- Reduced attention shifting ability: not just for movements.

Limbic system, prefrontal cortex and movement:

The limbic system lies in close proximity to the basal ganglia and the frontal
lobe
Emotions such as fear, anxiety, anger will have influence on movement

Limbic system = memory and emotions

Prefrontal cortex = planning and calculating

possible outcomes of a movement.

Thalamus and movement

- Transmission and some processing of afferent (sensory) and efferent

(motor) information
- Modulates sensory information
- Relays motor feedforward information from the basal ganglia and the
cerebellum to the cortical motor areas

Reticular formation

- Adjusts arousal and attention level during movement

 - Reticular formation is found in the brainstem. Vital centres for breathing
and circulation of the blood.

Brain stem and movement

- Adjusts the activity in the descending motor tracts/system for the control
of posture during movement.

Common conditions impacted by movement disorder:

Parkinson's Disease

- Gradual progressive death of neurons especially in substantia nigra of

basal ganglia. Dopamine deficiency.
- Affects 1: 340 people (Aust Statistic, 2015)
- Early onset <50 – strong genetic component.
- Late onset >50 – little or no heredity link.
- Neurons in substantial nigra decrease by 20%-30%.

Symptoms

- Muscle tremors are an involuntary, rhythmic muscle contraction leading

to shaking movements in one or more parts of the body.

- Rigidity - Stiff and aching muscles. One of the most common early signs
of Parkinson's is a reduced arm swing on one side when you walk. This is
caused by rigid muscles. Rigidity can also affect the muscles of the legs,
face, neck, or other parts of the body. It may cause muscles to feel tired
and achy.

- Slow, limited movement that is difficult to initiate, especially when you

try to move from a resting position. For instance, it may be hard to get out
of a chair or turn over in bed.

- Difficulty with walking and balance. A person with this disease is likely
to take small steps and shuffle with his or her feet close together, bend
forward slightly at the waist, and have trouble turning around. Balance
and posture problems may cause frequent falls. But these problems
usually don't happen until later on.
 - Freezing: a sudden, brief inability to move. It most often affects walking.

- Weak face & throat muscles. ‘Parkinson’s mask’. It may get harder to
talk and swallow. You may choke, cough, or drool. Speech becomes
softer and monotonous. Loss of movement in the muscles in the face can
cause a fixed, vacant facial expression, often called the "Parkinson's
mask."

- Slow at cognitive tasks (later stages).

- Some depression and cognitive deficits but no emotional outbursts.

Treatment for Parkinson's Disease

Most common treatment: L-Dpoa

- Dopamine-like drug that can cross blood-brain barrier (dopamine does

not).
- Effective in early to intermediate stages but some patients do not benefit
at all.
- Does not stop progression of the disease & may do harm.
- Side effects: nausea, restlessness, sleep problems, low blood pressure,
hallucinations, and delusions.

Huntington’s disease

- Severe neurological disorder.

- Affects 1: 10,000.
- Extensive damage to caudate nucleus, putamen & globus pallidus of
Basal Ganglia.
- Also some damage to cerebral cortex.
- Hereditary disease. No cure. Cause appears to be an anomaly of 4th
chromosome

Symptoms
 - Most often appear between 30-50 yrs.
- Begin with jerky arm movements (chorea), then facial twitch, later
tremors spread and develop into writhing.
- Cannot improve or learn new movements.
- Includes depression, memory impairment, anxiety, hallucinations - may
be misdiagnosed as schizophrenia.

Myasthenia Gravis

- Autoimmune disease that attacks the acetylcholine receptors at the

neuromusclular junctions.
- Prevents muscle contraction.

Symptoms:
- progressive weakness with rapid muscle fatigue.

Treatment:
- drugs intended to prolong acetylcholine action at the receptors.

Multiple Sclerosis

- Condition that attacks the myelin coating of axons within the brain, optic
nerves or spinal cord (CNS).
- Prevents efficient conduction of electrical impulses.

Symptoms:
- progressive weakness of targeted muscles. Effects variable &
unpredictable.

Treatment:
- drugs intended to shorten attacks, manage specific symptoms and slow
the progression of disease by reducing the relapse rate.
- Intensive physical activity appears to assist, especially in early stages.
Motor neuron disease (MND)

The devastating effects of the brain losing its ability to control body movements
are seen in Motor Neuron Disease (MND) – where progressive degeneration
and muscle wasting leads to some patients becoming “locked-in”, meaning they
can’t move or communicate in any way. Average life expectancy in 2.5 years
from onset of disease.

Symptoms:
- muscle aches, cramps, twitching
- clumsiness, stumbling
- weakness or changes in hands, arms, legs and voice
- slurred speech, swallowing or chewing difficulty
- fatigue
- muscle wasting, weight loss
- emotional lability – for example, where a slight upset can cause an
exaggerated response, such as crying or laughing
- cognitive change (changes in thought processes)
- respiratory changes

Treatment:
- MND is still incurable, but it is not untreatable, as many symptoms can
be managed.

- The drug riluzole – available on the Pharmaceutical Benefits Scheme –

has been demonstrated in clinical trials to prolong survival by several
months and may help people to remain in the milder phase of the disease
for longer.

- Research has shown that people live better and longer under the care of a
multidisciplinary team.

- Interventions such as assistance with nutritional intake and breathing

improve quality of life.

Therapy interventions
Strategies for movement disorders may include:

 Stretching and exercise

 Casting and splinting of upper limb
 Compensatory strategies
 Education
 Energy conservation techniques
 Positioning
 Motor retraining
 Facilitate improved dexterity and coordination

Neuroplasticity

As with other parts of the brain, when neurons of the primary motor cortex are
damaged they will never regrow or repair. However, the brain can heal itself
and regain some lost function through neuroplasticity. This means undamaged
parts can change their connections and remap to other areas of the body to take
over function, compensating for damaged parts of the motor cortex.
Neuroplasticity is the fundamental principle in rehabilitation, such as for people
following stroke. It enables people to regain motor function and recover.
Through neuroplasticity, the more a particular movement is performed, the
stronger the brain pathways for that movement become and the easier it gets to
perform that movement in the future.
Keep in mind there are some neurological conditions where damage to certain
brain areas will continue to progress (Multiple Sclerosis/Dementia) and
neuroplasticity may not be the best or most effective intervention you can utilise
with the person.

SENSe
OT's can assist clients to regain upper limb proprioception through an evidence-
based program called SENSe.
Facilitation techniques used in therapy:
- Tapping’ triceps (with fingers or a vibrator) stimulates the Muscle
Spindles to fire & produce a contraction in the weak muscle (e.g. in
stroke)
 - Prolonged slow stretch in spastic muscles deactivates the Muscle
Spindles, which leads to a relaxation in that muscle and excitation in the
antagonist (e.g. in serial casting, post ABI & post CVA). This decreases
the sensitivity of the stretch reflex & sets a new threshold.

Why is it important for OTs to know this?

- Firstly, it is interesting to know about your own body & how it works.
- Secondly, facilitation techniques used in therapy to either facilitate
inactive muscles or relax over active muscles and target the
proprioceptors.

OPI’s
How each individual will be affected by movement disorders will vary
considerably. This will all depend on the person's intrinsic and extrinsic factors.
Movement disorders affect all areas of a person's occupational performance,
from self care to domestic, to community and leisure/school/work as well. It is
important to listen to the individual person about what areas of occupational
performance are important to them and focus on these in your therapy.
Common OPI's for people with Movement Disorders include;

- Impaired walking around home and their community due to decreased

balance and coordination

- Difficulty writing/using cutlery/completing craft activities/making a hot

drink using the kettle or using a knife to cut and prepare food due to hand
tremors

- Decreased ability to roll out of bed/change position and increased risk of

pressure injury due to spasticity

- Decreased independence with dressing, such as doing up

buttons/shoelaces and buckles due to impaired coordination

- Difficulty fulfilling work roles, going out with friends, and doing the
shopping due to muscle fatigue and weakness
- There are many more OPIs that could be impacted by movement
disorders and they will vary for every person........