- this two-neuron path (2 neurons central and peripheral) , connecting the cerebral cortex with the skeletal (striated) muscles (cortical-muscular path). The pyramidal path is a pyramidal system, the system that provides arbitrary movements.

Central neuron

Central the neuron is located in the Y layer (a layer of large Betz pyramidal cells) of the anterior central gyrus, in the posterior sections of the superior and middle frontal gyri, and in the paracentral lobule. There is a clear somatic distribution of these cells. The cells located in the upper part of the precentral gyrus and in the paracentral lobule innervate the lower limb and trunk, located in its middle part - the upper limb. In the lower part of this gyrus, there are neurons that send impulses to the face, tongue, pharynx, larynx, chewing muscles.

The axons of these cells are in the form of two conductors:

1) cortico-spinal path (otherwise called the pyramidal tract) - from the upper two-thirds of the anterior central gyrus

2) cortico-bulbar tract - from the lower part of the anterior central gyrus) go from the cortex deep into the hemispheres, pass through the internal capsule (the cortico-bulbar path - in the knee area, and the cortico-spinal path through the anterior two-thirds of the posterior thigh of the internal capsule).

Then the legs of the brain, the bridge, the medulla oblongata pass, and at the border of the medulla oblongata and the spinal cord, the cortico-spinal tract undergoes an incomplete decussation. A large, crossed part of the path passes into the lateral column of the spinal cord and is called the main, or lateral, pyramidal bundle. The smaller uncrossed part passes into the anterior column of the spinal cord and is called the direct uncrossed bundle.

The fibers of the cortico-bulbar tract terminate at motor nuclei cranial nerves (Y, YII, IX, X, XI, XII ), and the fibers of the cortico-spinal tract - in anterior horns of the spinal cord . Moreover, the fibers of the cortico-bulbar tract are criss-crossed sequentially as they approach the corresponding nuclei of the cranial nerves (“supranuclear” chiasm). For the oculomotor, masticatory muscles, muscles of the pharynx, larynx, neck, trunk and perineum, there is a bilateral cortical innervation, i.e., to a part of the motor nuclei of the cranial nerves and to some levels of the anterior horns of the spinal cord, the fibers of the central motor neurons approach not only from the opposite side, but also with his own, thus ensuring the approach of impulses from the cortex not only of the opposite, but also of his own hemisphere. Unilateral (only from the opposite hemisphere) innervation have limbs, tongue, lower facial muscles. The axons of the motor neurons of the spinal cord are sent to the corresponding muscles as part of the anterior roots, then the spinal nerves, plexuses, and finally the peripheral nerve trunks.

peripheral neuron

peripheral neuron starts from the places where the first one ended: the fibers of the dagger-bulbar path ended on the nuclei of the cranial nerves, which means they go as part of the cranial nerves, and the cortico-spinal path ended in the anterior horns of the spinal cord, which means it goes as part of the anterior roots of the spinal nerves, then the peripheral nerves, reaching the synapse.

Central and peripheral paralysis develop with the homonymous lesion of a neuron.

8.3. Functional differences of motor neurons

Motor neuron size determines a very important physiological property of it - the threshold of excitation. The smaller the motor neuron, the easier it is to fire. Or, in other words, in order to excite a small motor neuron, it is necessary to exert a smaller excitatory influence on it than on a large motor neuron. The difference in excitability (thresholds) is due to the fact that the action of excitatory synapses on a small motor neuron is more effective than on a large motor neuron. Small motor neurons are low threshold motor neurons, while large motor neurons are high threshold motor neurons.

Pulse frequency motor neurons, like other neurons, is determined by the intensity of excitatory synaptic influences from other neurons. The higher the intensity, the higher the pulse frequency. However, the increase in the frequency of motor neuron impulses is not unlimited. It is limited by a special mechanism in the spinal cord. From the axon of the motor neuron, even before leaving the spinal cord, a recurrent lateral branch departs, which, branching in the gray matter of the spinal cord, forms synaptic contacts with special neurons - inhibitory cellsrenshaw. The axons of Renshaw cells terminate in inhibitory synapses on motor neurons. Impulses arising in motor neurons propagate along the main axon to the muscle, and along the return axon branch to Renshaw cells, exciting them. Excitation of Renshaw cells leads to inhibition of motor neurons. The more often motor neurons begin to send impulses, the stronger the excitation of Renshaw cells and the greater the inhibitory effect of Renshaw cells on motor neurons. As a result of the action of Renshaw cells, a decrease in the frequency of impulses of motor neurons occurs.

The inhibitory effect of Renshaw cells on small motor neurons is stronger than on large ones. This explains why small motor neurons fire at a slower rate than large motor neurons. The frequency of impulses of small motor neurons usually does not exceed 20–25 impulses per 1 second, and the frequency of impulses of large motor neurons can reach 40–50 impulses per 1 second. In this regard, small motor neurons are also called "slow", and large motor neurons - "fast".

8.4. Mechanism of neuromuscular transmission

Impulses propagating along the terminal branches of the axon of a motor neuron reach almost simultaneously all the muscle fibers of a given motor unit. The propagation of the impulse along the terminal branch of the axon leads to depolarization of its presynaptic membrane. In this regard, the permeability of the presynaptic membrane changes and the mediator acetylcholine located in the terminal branch is released into the synaptic cleft. An enzyme found in the synaptic cleft acetylcholinesterase destroys within a few milliseconds acetylcholine. Therefore, the effect of acetylcholine on the muscle fiber membrane is very short-lived. If the motor neuron sends impulses for a long time and at a high frequency, then the reserves of acetylcholine in the terminal branches are depleted and transmission through the neuromuscular synapse stops. In addition, when impulses along the axon follow at a high frequency, acetylcholinesterase does not have time to destroy acetylcholine released into the synaptic cleft. The concentration of acetylcholine in the synaptic cleft increases, which also leads to the cessation of neuromuscular transmission. Both of these factors can occur during intense and prolonged muscular work and lead to a decrease in muscle performance (fatigue).

The action of acetylcholine causes a change in the ion permeability of the postsynaptic membrane of the muscle fiber. An ionic current begins to flow through it, which leads to a decrease in the potential of the muscle fiber membrane. This decrease leads to the development of an action potential that propagates along the membrane of the muscle fiber. Simultaneously with the propagation of the action potential along the muscle fiber, a wave of contraction runs. Since the impulse from the motor neuron comes to all terminal branches of the axon almost simultaneously, the contraction of all muscle fibers of one motor unit also occurs simultaneously. All muscle fibers of a motor unit work as a whole.

8.5. Single cut

In response to an impulse from a motor neuron, all muscle fibers of the motor unit respond single contraction. It consists of two phases - the lifting phase voltage(or shortening phases) and phases relaxation(or elongation phases). The tension developed by each muscle fiber during a single contraction is a constant value for each muscle fiber. Therefore, the tension developed by a motor unit during a single contraction is also constant and is determined by the number of muscle fibers that make up this motor unit. The more muscle fibers are included in the composition of the motor unit, the more tension it develops. Motor units differ from each other in the duration of a single contraction. The duration of a single contraction of the slowest motor can reach 0.2 seconds; the duration of a single contraction of fast motor units is much shorter - up to 0.05 sec. In both types of motor units, the tension-up phase lasts less than the relaxation phase. So, with a total duration of a single contraction of a slow motor unit of 0.1 sec. the tension rise phase lasts about 0.04 sec., and the relaxation phase lasts about 0.06 sec. With the duration of a single contraction of a fast motor unit of 0.05 sec. the duration of the tension rise phase is approximately 0.02 seconds, and the relaxation phase is 0.03 seconds.

The speed of muscle contraction as a whole depends on the ratio of slow and fast motor units in it. Muscles dominated by slow motor units are slow muscles, and muscles dominated by fast motor units are fast muscles.

The ratio of the number of fast and slow motor units in a muscle depends on its function in the body. Thus, the internal head of the gastrocnemius muscle is involved in locomotor movements and jumps and is among the fast muscles, the soleus muscle plays an important role in maintaining a vertical posture in humans and is among the slow muscles.

8.6. tetanic contraction

Motoneurons usually send to the muscles not a single impulse, but a series of impulses. The response of muscle fibers to a series of impulses depends on the frequency of impulses of the motor neuron.

Let us consider the features of the response to a series of impulses of muscle fibers of a slow motor unit with a duration of a single contraction of 0.1 sec. Until the impulse frequency of the motor neuron of this motor unit does not exceed 10 impulses per 1 second, i.e., the impulses follow each other with an interval of 0.1 seconds. and more, the slow motor unit works in the mode of single contractions. This means that each new contraction of muscle fibers begins after the end of the relaxation phase in the previous cycle of contraction.

If the impulse frequency of a slow motor neuron becomes more than 10 impulses per 1 second, i.e. impulses follow each other with an interval of less than 0.1 second, the motor unit starts to work in the mode tetanic abbreviations. This means that each new contraction of the muscle fibers of the motor unit begins even before the end of the previous contraction. Successive contractions are superimposed on each other, so that the tension developed by the muscle fibers of a given motor unit increases and becomes greater than with single contractions. Within certain limits, the more often the motor neuron sends impulses, the more tension the motor unit develops, since each next increase in tension begins against the background of an increasing tension left from the previous contraction.

Any motor unit develops maximum tetanic tension in those cases when its motor neuron sends impulses at a frequency at which each new contraction begins at the phase, or peak, of the rise in tension of the previous contraction. It is easy to calculate: the peak of the rise in tension during a single contraction is reached in a slow motor unit in about 0.04 seconds. after the start of contraction. Therefore, the maximum summation will be reached when the next contraction occurs in 0.04 sec. after the beginning of the previous one, i.e., at intervals between impulses of a “slow” motor neuron of 0.04 sec., which corresponds to an impulse frequency of 25 impulses per 1 sec.

So, if the motor neuron of a slow motor unit sends impulses with a frequency of less than 10 pulses / sec, then the motor unit works in the mode of a single contraction. When the motoneuron impulse frequency exceeds 10 imp/sec, the motor unit starts to work in the tetanic contraction mode, and within the increase from 10 to 25 imp/sec, the higher the motoneuron impulse frequency, the more tension the motor unit develops. In this frequency range of motor neuron impulses, the muscle fibers controlled by it work in the mode dentate tetanus(alternating rise and fall of stresses).

The maximum tetanic tension of the slow motor unit is achieved at a motoneuron impulse frequency of 25 imp/sec. At such a frequency of motor neuron impulses, the muscle fibers of the motor unit work in the mode smooth tetanus(there are no sharp fluctuations in the tension of muscle fibers). An increase in the frequency of motor neuron impulses in excess of 25 imp/sec no longer causes a further increase in the tension of slow muscle fibers. Therefore, for a “slow” motor neuron, there is no “meaning” to work with a frequency of more than 25 pulses / sec, since a further increase in frequency will still not increase the tension developed by its slow muscle fibers, but will be tiring for the motor neuron itself.

It is easy to calculate that for a fast motor unit with a total duration of a single contraction of muscle fibers of 0.05 sec. the mode of single contractions will be maintained until the motoneuron impulse frequency reaches 20 imp/sec, i.e., at intervals between impulses of more than 0.05 sec. With a motoneuron firing frequency of more than 20 imp/sec, muscle fibers operate in the dentate tetanus mode, and the higher the motoneuron firing frequency, the greater the tension developed by the muscle fibers of the motor unit. The maximum voltage of a fast motor unit occurs at a motoneuron impulse frequency of 50 pulses/sec and higher, since the peak of the voltage rise in such a motor unit is reached after about 0.02 sec. after the start of a single contraction.

8.7. Comparison of single and tetanic contractions

At solitary contraction in the phase of tension rise, some energy potential of the muscle is consumed, and in the relaxation phase it is restored. Therefore, if each subsequent contraction of muscle fibers begins after the end of the previous one, then during work in this mode, the muscle fibers have time to restore the potential wasted in the contraction phase. In this regard, the mode of single contractions for muscle fibers is practically tireless. In this mode, motor units can work for a long time.

At tetanic mode contractions, each subsequent contraction begins even before the end of the relaxation phase (or even before the start of the relaxation phase) of the previous contraction. Therefore, work in a tetanic mode is work on "duty" and, therefore, cannot continue for a long time. In contrast to the mode of single contractions, tetanic contraction is tiring for muscle fibers.

The ratio of the maximum tetanic tension, which the motor unit develops in the mode of maximum (smooth) tetanus, to the tension during its single contraction is called tetanic index. This index shows what increase in the magnitude of the tension of the muscle fibers of the motor unit can be obtained by increasing the frequency of motor neuron impulses. The tetanic index for different motor units is from 0.5 to 10 or more. This means that by increasing the frequency of motor neuron impulses, the contribution of one motor unit to the total tension of the entire muscle can increase several times.

8.8. Muscle tension regulation

Movement control is associated with the regulation of the tension of the muscles that carry out the movement.

Muscle tension is determined by the following three factors:

1) the number of active motor units;

2) the mode of operation of motor units, which, as is known, depends on the frequency of impulses of motoneurons;

3) connection in time of activity of different motor units.

8.8.1. Number of active motor units

active motor unit is such a unit in which 1) the motor neuron sends impulses to its muscle fibers and 2) the muscle fibers contract in response to these impulses. The greater the number of active motor units, the greater the muscle tension.

The number of active motor units depends on the intensity of excitatory influences that the motor neurons of a given muscle are exposed to from neurons of higher motor levels, receptors and neurons of their own spinal level. For the development of a small muscle tension, a correspondingly relatively small intensity of excitatory influences on its motor neurons is required. Since small motor neurons are relatively low-threshold, their activation requires a relatively low level of excitatory influences. Therefore, from the set of motor units that make up the muscle, its weak tensions are provided mainly by the activity of relatively low-threshold, small, motor units. The more tension a muscle should develop, the greater should be the intensity of excitatory influences on its motor neurons. At the same time, in addition to low-threshold, small, motor units, more and more high-threshold (larger in size) motor units become active. With an increase in the number of active motor units, the tension developed by the muscle increases. Significant muscle tensions are provided by the activity of different motor units, ranging from its low threshold (small) to high threshold (large). Consequently, the smallest motor units are active at any (both small and large) muscle tension, while large motor units are active only at high muscle tension.

8.8.2. Mode of activity of motor units

Within certain limits, the greater the frequency of motor neuron impulses, the greater the tension developed by the motor unit and, consequently, the greater its contribution to the total tension of the muscle. Thus, along with the number of active motor units (motor neurons), an important factor in the regulation of muscle tension is the frequency of motoneuron firing, which determines the contribution of the active motor unit to the total tension.

The frequency of impulsation of motor neurons, as is known, depends on the intensity of excitatory influences to which motor neurons are exposed. Therefore, when the intensity of excitatory influences on motor neurons is low, then low-threshold, small, motor neurons work, and the frequency of their impulses is relatively small. Accordingly, small motor units work in this case in the mode of single contractions. Such activity of motor units provides only a slight muscle tension, which, however, is sufficient, for example, to maintain a vertical body posture. In this regard, it is understandable why, knowing the activity of the muscles can last for many hours without fatigue.

Greater muscle tension occurs due to increased excitatory influences on its motor neurons. This amplification leads not only to the inclusion of new, higher-threshold motor neurons, but also to an increase in the firing frequency of relatively low-threshold motor neurons. At the same time, for the most high-threshold of the working motoneurons, the intensity of excitatory influences is insufficient to cause their high-frequency discharge. Therefore, from the set of active motor units, the lower threshold ones work with a relatively high frequency for themselves (in the mode of tetanic contraction), and the most high-threshold active motor units work in the mode of single contractions.

At very high muscle tensions, the vast majority (if not all) of active motor units work in a tetanic mode, and therefore high muscle tensions can be maintained for a very short time.

8.8.3. Relationship in time of activity of different motor units

In addition to the two factors already considered, muscle tension to a certain extent depends on how the impulses sent by different motor neurons of the muscle are connected in time. To make this clear, consider a simplified example of the activity of three motor units of one muscle, working in single contraction mode. In one case, all three motor units contract simultaneously, since the motor neurons of these three motor units send impulses simultaneously (synchronously). In another case, the motor units do not work simultaneously (asynchronously), so that the phases of contractions of their muscle fibers do not coincide in time.

It is quite clear that in the first case the total muscle tension is greater than in the second, but the tension fluctuations are very large - from maximum to minimum. In the second case, the total muscle tension is less than in the first, but the voltage fluctuations are much smaller. From this example, it is clear that if the motor units work in single contraction mode, but asynchronously, then the total tension of the entire muscle fluctuates slightly. The more asynchronously working motor units, the less fluctuations in muscle tension, the more smoothly the movement is performed or the less fluctuations in posture (less amplitude of physiological tremor). Under normal conditions, most of the motor units of one muscle work asynchronously, independently of each other, which ensures the smoothness of its contraction. With fatigue associated with large and prolonged muscle work, the normal activity of motor units is disrupted and they begin to work. simultaneously. As a result, movements lose their smoothness, their accuracy is disturbed, and fatigue tremor.

If the motor units work in the mode of smooth tetanus or a serrated tetanus close to it, then the interconnectedness of the activity of motor units over time is no longer of serious importance, since the level of tension of each of the motor units is maintained almost constant. Consequently, the moments of the beginning of each subsequent contraction of the motor unit are also insignificant, since their coincidences or mismatches almost do not affect the total tension and fluctuations in muscle tension.

8.9. Energy of muscle contraction

The work of a muscle is the result of the conversion of the chemical energy of energy substances contained in the muscle into mechanical energy. In this case, the main energy substance is adenosine triphosphoric acid(otherwise adenosine triphosphate), which is usually denoted by three letters - ATP. It is able to easily split off one molecule of phosphoric acid, turning into adenosine diphosphoric acid (ADP); this releases a lot of energy (about 8 kcal). The breakdown of ATP occurs under the influence of an enzyme, the role of which, when a muscle is excited, is performed by the muscle protein itself - myosin. Due to the splitting of ATP, the released chemical energy is converted into mechanical energy, manifested in the mutual movement of actin and myosin filaments. It is characteristic that chemical energy is transformed in the muscle directly into mechanical energy without an intermediate stage - transformation into thermal energy. This muscle as an engine differs from other known engines created by man. Chemical energy in it is used very fully, with negligible losses.

The amount of ATP in the muscle is limited - 0.75% of the muscle weight. However, even with continuous work, ATP reserves are not depleted, because it is continuously re-formed in muscle tissue. The source of its formation is its own decay product, i.e. ADP. For the reverse conversion of ADP to ATP, phosphoric acid must be added to ADP again. This is what happens in reality. However, if the breakdown of ATP is accompanied by the release of energy, then its synthesis requires the absorption of energy. This energy can come from three sources.

1 – breakdown of creatine phosphoric acid, or, otherwise, creantine phosphate (CrF). It is a compound of a nitrogen-containing substance - creatine with phosphoric acid. During the breakdown of CRF, phosphoric acid is released, which, entering into combination with ADP, forms ATP:

2 – anaerobic breakdown of glycogen(glycogenolysis) or glucose (glycolysis) to lactic acid. Actually, it is not the carbohydrate itself that undergoes decomposition, but its combination with phosphoric acid - glucose phosphate. This compound sequentially decomposes into a number of intermediate substances, while phosphoric acid is cleaved off and attached to ADP for the synthesis of ATP. The end product of the breakdown of carbohydrates is lactic acid. Part of the resulting lactic acid can be further subjected to aerobic oxidation to carbon dioxide and water. The resulting energy goes to the reverse synthesis (resynthesis) of carbohydrate from other parts of lactic acid. Usually, due to the energy of aerobic oxidation of one lactic acid molecule, 4–6 other lactic acid molecules are resynthesized into carbohydrates. This testifies to the great efficiency of the use of carbohydrate energy. It is believed that the resynthesis of carbohydrates to glycogen due to the energy of aerobic oxidation of lactic acid occurs mainly in the liver, where lactic acid is delivered by blood from working muscles.

3 – aerobic oxidation of carbohydrates and fats. The process of anaerobic decomposition of carbohydrates may not be completed to lactic acid, but oxygen is added at one of the intermediate stages. The resulting energy is used to add phosphoric acid to ADP, released during the breakdown of carbohydrates. The energy of aerobic fat oxidation is also used for ATP resynthesis. Fat is broken down to glycerol and fatty acids, and the latter, by appropriate transformations with the addition of phosphoric acid, are made capable of aerobic oxidation, in which the addition of phosphoric acid to ADP and the resynthesis of ATP occurs.

With single short-term muscle tensions (jumping, throwing, lifting a barbell, boxing punch, quick wrestling techniques, etc.), ATP resynthesis occurs due to the energy of CRF. During longer work, requiring 10–20 seconds. (running 100–200 m), ATP resynthesis occurs with the participation of the anaerobic breakdown of carbohydrates, i.e., glycolysis processes. With even longer work, ATP resynthesis can be determined by aerobic oxidation of carbohydrates.

If breathing is excluded or insufficient, that is, if work is done only or mainly due to anaerobic processes, then anaerobic decay products accumulate. These are mainly ADP, creatine and lactic acid. Elimination of these substances after work is carried out with the participation of oxygen. The increased amount of oxygen absorbed after work is called oxygen debt. That part of the oxygen debt, which goes to the oxidation of lactic acid, is called lactate oxygen debt. Another part of the oxygen debt is spent on the reactions necessary to restore CRF and ATP. It is called alactic oxygen debt. Thus, the oxygen consumed after work contributes to the resynthesis of the main energy substances: ATP, CRF and glycogen.

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Peripheral motor neurons

Neurons are functionally divided into large alpha motor neurons, small alpha motor neurons, and gamma motor neurons. All of these motor neurons are located in the anterior horns of the spinal cord. Large alpha motor neurons innervate white muscle fibers, causing rapid physical contractions. Small alpha motor neurons innervate red muscle fibers and provide the tonic component. Gamma motor neurons direct axons to the intrafusal muscle fibers of the neuromuscular spindle. Large alpha cells are associated with giant cells in the cerebral cortex. Small alpha cells have a connection with the extrapyramidal system. Gamma cells regulate the state of muscle proprioceptors.

The structure of the muscle spindle

Each striated muscle contains muscle spindles. Muscle spindles, as the name suggests, are spindle-shaped, a few millimeters long and a few tenths of a millimeter in diameter. The spindles are located in the thickness of the muscle parallel to the usual muscle fibers. The muscle spindle has a connective tissue capsule. The capsule provides mechanical protection for the spindle elements located in the capsule cavity, regulates the chemical liquid medium of these elements and thus ensures their interaction. In the cavity of the muscle spindle capsule there are several special muscle fibers that are capable of contraction, but differ from ordinary muscle fibers of the muscle both in structure and in function.

These muscle fibers located inside the capsule were called intrafusal muscle fibers (Latin: intra - inside; fusus - spindle); ordinary muscle fibers are called extrafusal muscle fibers (Latin: extra - outside, outside; fusus - spindle). Intrafusal muscle fibers are thinner and shorter than extrafusal muscle fibers.

4.1. pyramid system

There are two main types of movements - involuntary and voluntary. Involuntary include simple automatic movements carried out by the segmental apparatus of the spinal cord and brain stem in the form of a simple reflex act. Arbitrary purposeful movements are acts of human motor behavior. Special voluntary movements (behavioral, labor, etc.) are carried out with the leading participation of the cerebral cortex, as well as the extrapyramidal system and the segmental apparatus of the spinal cord. In humans and higher animals, the implementation of voluntary movements is associated with a pyramidal system consisting of two neurons - central and peripheral.

Central motor neuron. Voluntary muscle movements occur as a result of impulses traveling along long nerve fibers from the cerebral cortex to the cells of the anterior horns of the spinal cord. These fibers form the motor (cortical-spinal), or pyramidal, path.

The bodies of the central motor neurons are located in the precentral gyrus in cytoarchitectonic fields 4 and 6 (Fig. 4.1). This narrow zone extends along the central fissure from the lateral (Sylvian) sulcus to the anterior part of the paracentral lobule on the medial surface of the hemisphere, parallel to the sensory cortex of the postcentral gyrus. The vast majority of motor neurons lie in the 5th cortical layer of field 4, although they are also found in neighboring cortical fields. Small pyramidal, or fusiform (fusiform) cells predominate, providing the basis for 40% of the fibers of the pyramidal pathway. Betz's giant pyramidal cells have thick myelin sheathed axons for precise, well-coordinated movement.

The neurons that innervate the pharynx and larynx are located in the lower part of the precentral gyrus. Next in ascending order are the neurons that innervate the face, arm, torso, and leg. Thus, all parts of the human body are projected in the precentral gyrus, as it were, upside down.

Rice. 4.1. Pyramid system (diagram).

BUT- Pyramidal path: 1 - cerebral cortex; 2 - internal capsule; 3 - leg of the brain; 4 - bridge; 5 - cross of pyramids; 6 - lateral cortical-spinal (pyramidal) path; 7 - spinal cord; 8 - anterior cortical-spinal tract; 9 - peripheral nerve; III, VI, VII, IX, X, XI, XII - cranial nerves. B- Convexital surface of the cerebral cortex (fields 4 and 6); topographic projection of motor functions: 1 - leg; 2 - torso; 3 - hand; 4 - brush; 5 - face. IN- Horizontal section through the internal capsule, the location of the main pathways: 6 - visual and auditory radiance; 7 - temporal-bridge fibers and parietal-occipital-bridge bundle; 8 - thalamic fibers; 9 - cortical-spinal fibers to the lower limb; 10 - cortical-spinal fibers to the muscles of the body; 11 - cortical-spinal fibers to the upper limb; 12 - cortical-nuclear pathway; 13 - frontal bridge path; 14 - cortical-thalamic path; 15 - anterior leg of the inner capsule; 16 - knee of the inner capsule; 17 - rear leg of the inner capsule. G- Anterior surface of the brain stem: 18 - cross of the pyramids

Axons of motoneurons form two descending pathways - corticonuclear, heading to the nuclei of cranial nerves, and more powerful - cortical-spinal, going to the anterior horns of the spinal cord. The fibers of the pyramidal tract, leaving the motor cortex, pass through the corona radiata of the white matter of the brain and converge to the internal capsule. In somatotopic order, they pass through the internal capsule (in the knee - the cortical-nuclear path, in the anterior 2/3 of the posterior thigh - the cortical-spinal path) and go in the middle part of the legs of the brain, descend through each half of the base of the bridge, being surrounded by numerous nerve cells of the nuclei bridge and fibers of various systems.

At the border of the medulla oblongata and spinal cord, the pyramidal pathway becomes visible from the outside, its fibers form elongated pyramids on both sides of the midline of the medulla oblongata (hence its name). In the lower part of the medulla oblongata, 80-85% of the fibers of each pyramidal tract passes to the opposite side, forming the lateral pyramidal tract. The remaining fibers continue to descend in the homolateral anterior cords as part of the anterior pyramidal tract. In the cervical and thoracic sections of the spinal cord, its fibers are connected to motor neurons that provide bilateral innervation of the muscles of the neck, trunk, respiratory muscles, so that breathing remains intact even with a gross unilateral lesion.

The fibers that have passed to the opposite side descend as part of the lateral pyramidal pathway in the lateral cords. About 90% of the fibers form synapses with interneurons, which, in turn, connect with large α- and γ-motoneurons of the anterior horn of the spinal cord.

The fibers that form the cortical-nuclear pathway are sent to the motor nuclei located in the brain stem (V, VII, IX, X, XI, XII) of the cranial nerves, and provide motor innervation of the facial muscles. The motor nuclei of the cranial nerves are homologues of the anterior horns of the spinal cord.

Noteworthy is another bundle of fibers, starting in field 8, which provides cortical innervation of the gaze, and not in the precentral gyrus. The impulses going along this bundle provide friendly movements of the eyeballs in the opposite direction. The fibers of this bundle at the level of the radiant crown join the pyramidal pathway. Then they pass more ventrally in the posterior crus of the internal capsule, turn caudally and go to the nuclei of the III, IV, VI cranial nerves.

It should be borne in mind that only a part of the fibers of the pyramidal pathway makes up the oligosynaptic two-neuron pathway. A significant part of the descending fibers forms polysynaptic pathways that carry information from various parts of the nervous system. Along with afferent fibers entering the spinal cord through the posterior roots and carrying information from receptors, oligo- and polysynaptic fibers modulate the activity of motor neurons (Fig. 4.2, 4.3).

Peripheral motor neuron. In the anterior horns of the spinal cord lie motor neurons - large and small a- and 7-cells. The neurons of the anterior horns are multipolar. Their dendrites have multiple synaptic

connections with various afferent and efferent systems.

Large α-cells with a thick and fast-conducting axon carry out rapid muscle contractions and are associated with giant cells of the cerebral cortex. Small a-cells with a thinner axon perform a tonic function and receive information from the extrapyramidal system. 7-cells with a thin and slowly conducting axon innervate proprioceptive muscle spindles, regulating their functional state. 7-Motoneurons are under the influence of the descending pyramidal, reticular-spinal, vestibulospinal tracts. The efferent influences of 7-fibers provide fine regulation of voluntary movements and the possibility of regulating the strength of the response of receptors to stretch (the 7-motor neuron-spindle system).

In addition to direct motor neurons, in the anterior horns of the spinal cord there is a system of intercalary neurons that provide

Rice. 4.2. Conducting pathways of the spinal cord (scheme).

1 - wedge-shaped bundle; 2 - thin beam; 3 - posterior spinal-cerebellar path; 4 - anterior spinal-cerebellar path; 5 - lateral dorsal-thalamic pathway; 6 - dorsal tract; 7 - dorsal-olive path; 8 - anterior spinal-thalamic path; 9 - front own bundles; 10 - anterior cortical-spinal tract; 11 - occlusal-spinal path; 12 - pre-door-spinal path; 13 - olive-spinal path; 14 - red nuclear-spinal path; 15 - lateral corticospinal path; 16 - rear own bundles

Rice. 4.3. Topography of the white matter of the spinal cord (diagram). 1 - anterior funiculus: paths from the cervical, thoracic and lumbar segments are marked in blue, purple - from the sacral; 2 - lateral funiculus: paths from the cervical segments are indicated in blue, from the thoracic segments in blue, and from the lumbar segments in purple; 3 - posterior cord: blue indicates paths from the cervical segments, blue - from the thoracic, dark blue - from the lumbar, purple - from the sacral

regulation of signal transmission from the higher parts of the central nervous system, peripheral receptors responsible for the interaction of adjacent segments of the spinal cord. Some of them have a facilitating, others - inhibitory effect (Renshaw cells).

In the anterior horns, motor neurons form groups organized into columns in several segments. There is a certain somatotopic order in these columns (Fig. 4.4). In the cervical region, the laterally located motor neurons of the anterior horn innervate the hand and arm, and the motor neurons of the distally lying columns innervate the muscles of the neck and chest. In the lumbar region, the motor neurons that innervate the foot and leg are also located laterally, and those innervating the muscles of the body are medially.

Axons of motor neurons leave the spinal cord as part of the anterior roots, unite with the posterior roots, forming a common root, and, as part of the peripheral nerves, go to the striated muscles (Fig. 4.5). The well-myelinated, fast-conducting axons of large a-cells run directly to the striated muscle, forming neuromuscular junctions, or end plates. The composition of the nerves also includes efferent and afferent fibers emanating from the lateral horns of the spinal cord.

A skeletal muscle fiber is innervated by the axon of only one a-motoneuron, but each a-motoneuron can innervate a different number of skeletal muscle fibers. The number of muscle fibers innervated by one α-motor neuron depends on the nature of regulation: for example, in muscles with fine motor skills (for example, eye, articular muscles), one α-motor neuron innervates only a few fibers, and in

Rice. 4.4. Topography of the motor nuclei in the anterior horns of the spinal cord at the level of the cervical segment (diagram). Left - general distribution of cells of the anterior horn; on the right - nuclei: 1 - posteromedial; 2 - anteromedial; 3 - front; 4 - central; 5 - anterolateral; 6 - posterolateral; 7 - posterolateral; I - gamma efferent fibers from small cells of the anterior horns to neuromuscular spindles; II - somatic efferent fibers, giving collaterals to the medially located Renshaw cells; III - gelatinous substance

Rice. 4.5. Cross section of the spine and spinal cord (diagram). 1 - spinous process of the vertebra; 2 - synapse; 3 - skin receptor; 4 - afferent (sensitive) fibers; 5 - muscle; 6 - efferent (motor) fibers; 7 - vertebral body; 8 - node of the sympathetic trunk; 9 - spinal (sensitive) node; 10 - gray matter of the spinal cord; 11 - white matter of the spinal cord

muscles of the proximal limbs or in the rectus dorsi muscles, one α-motor neuron innervates thousands of fibers.

α-Motoneuron, its motor axon and all the muscle fibers innervated by it form the so-called motor unit, which is the main element of the motor act. Under physiological conditions, the discharge of an α-motor neuron leads to a contraction of all muscle fibers of the motor unit.

The skeletal muscle fibers of a single motor unit are called a muscle unit. All fibers of one muscle unit belong to the same histochemical type: I, IIB or IIA. Motor units that contract slowly and are resistant to fatigue are classified as slow (S - slow) and consist of type I fibers. Muscle units of group S are provided with energy due to oxidative metabolism, they are characterized by weak contractions. motor units,

leading to fast phasic single muscle contractions are divided into two groups: fast fatigued (FF - fast fatigable) and fast, fatigue resistant (FR - fast fatigue resistant). The FF group includes type IIB muscle fibers with glycolytic energy metabolism and strong contractions but rapid fatigue. The FR group includes type IIA muscle fibers with oxidative metabolism and high resistance to fatigue, the strength of their contraction is intermediate.

In addition to large and small α-motor neurons, the anterior horns contain numerous 7-motoneurons - smaller cells with a soma diameter of up to 35 microns. The dendrites of γ-motor neurons are less branched and are oriented mainly in the transverse plane. 7-motoneurons projecting to a specific muscle are located in the same motor nucleus as α-motoneurons. A thin, slowly conducting axon of γ-motoneurons innervates the intrafusal muscle fibers that make up the proprioreceptors of the muscle spindle.

Large a-cells are associated with giant cells of the cerebral cortex. Small a-cells have a connection with the extrapyramidal system. Through 7-cells, the state of muscle proprioceptors is regulated. Among the various muscle receptors, the neuromuscular spindles are the most important.

Afferent fibers, called annular, or primary, endings, have a fairly thick myelin coating and are fast-conducting fibers. Extrafusal fibers in a relaxed state have a constant length. When the muscle is stretched, the spindle is stretched. The ring-spiral endings respond to stretching by generating an action potential, which is transmitted to the large motor neuron along the fast-conducting afferent fibers, and then again along the fast-conducting thick efferent fibers - the extrafusal muscles. The muscle contracts, its original length is restored. Any stretching of the muscle activates this mechanism. Tapping the tendon of the muscle causes it to stretch. The spindles react immediately. When the impulse reaches the motor neurons of the anterior horn of the spinal cord, they react by causing a short contraction. This monosynaptic transmission is the basis for all proprioceptive reflexes. The reflex arc covers no more than 1-2 segments of the spinal cord, which is important in determining the localization of the lesion.

Many muscle spindles have not only primary but also secondary endings. These endings also respond to stretch stimuli. Their action potential propagates in a central direction along

thin fibers communicating with intercalary neurons responsible for the reciprocal actions of the corresponding antagonist muscles.

Only a small number of proprioceptive impulses reach the cerebral cortex, most are transmitted through feedback rings and do not reach the cortical level. These are elements of reflexes that serve as the basis for voluntary and other movements, as well as static reflexes that counteract gravity.

Both with voluntary effort and with reflex movement, the thinnest axons are the first to enter into activity. Their motor units generate very weak contractions, which allows fine regulation of the initial phase of muscle contraction. As the motor units are involved, α-motor neurons with an axon of an ever larger diameter are gradually turned on, which is accompanied by an increase in muscle tension. The sequence of involvement of motor units corresponds to the order of increase in the diameter of their axon (principle of proportionality).

Research methodology

Inspection, palpation and measurement of muscle volume are carried out, the volume of active and passive movements, muscle strength, muscle tone, rhythm of active movements and reflexes are determined. Electrophysiological methods are used to establish the nature and localization of movement disorders with clinically insignificant symptoms.

The study of motor function begins with an examination of the muscles. Pay attention to atrophy or hypertrophy. Measuring the circumference of the muscles with a centimeter tape, one can assess the severity of trophic disorders. Sometimes fibrillar and fascicular twitches can be seen.

Active movements are checked sequentially in all joints (Table 4.1) and are performed by the subject. They may be absent or be limited in volume and weakened. The complete absence of active movements is called paralysis, or plegia, the limitation of range of motion or a decrease in their strength is called paresis. Paralysis or paresis of one limb is called monoplegia, or monoparesis. Paralysis or paresis of both arms is called upper paraplegia, or paraparesis, paralysis, or paraparesis of the legs - lower paraplegia, or paraparesis. Paralysis or paresis of two limbs of the same name is called hemiplegia, or hemiparesis, paralysis of three limbs - triplegia, paralysis of four limbs - quadriplegia, or tetraplegia.

Table 4.1. Peripheral and segmental muscle innervation

Continuation of table 4.1.

Continuation of table 4.1.

End of table 4.1.

Passive movements are determined with complete relaxation of the muscles of the subject, which makes it possible to exclude a local process (for example, changes in the joints), which limits active movements. The study of passive movements is the main method for studying muscle tone.

Investigate the volume of passive movements in the joints of the upper limb: shoulder, elbow, wrist (flexion and extension, pronation and supination), finger movements (flexion, extension, abduction, adduction, opposition of the i finger to the little finger), passive movements in the joints of the lower extremities: hip, knee, ankle (flexion and extension, rotation outward and inward), flexion and extension of the fingers.

Muscle strength is determined sequentially in all groups with active resistance of the patient. For example, when examining the strength of the muscles of the shoulder girdle, the patient is asked to raise his arm to a horizontal level, resisting the examiner's attempt to lower his arm; then they offer to raise both hands above the horizontal line and hold them, offering resistance. To determine the strength of the muscles of the forearm, the patient is asked to bend the arm at the elbow joint, and the examiner tries to straighten it; also evaluate the strength of the abductors and adductors of the shoulder. To assess the strength of the muscles of the forearm, the patient is asked to

giving to perform pronation and supination, flexion and extension of the hand with resistance during the movement. To determine the strength of the muscles of the fingers, the patient is asked to make a “ring” of the first finger and successively each of the others, and the examiner tries to break it. They check the strength when the V finger is abducted from the IV and the other fingers are brought together, when the hand is clenched into a fist. The strength of the muscles of the pelvic girdle and thigh is examined when asked to raise, lower, adduct and abduct the thigh, while providing resistance. The strength of the thigh muscles is examined, inviting the patient to bend and straighten the leg at the knee joint. To check the strength of the muscles of the lower leg, the patient is asked to bend the foot, and the examiner keeps it unbent; then they give the task to unbend the foot bent at the ankle joint, overcoming the resistance of the examiner. The strength of the muscles of the toes is also determined when the examiner tries to bend and unbend the fingers and separately bend and unbend the i-th finger.

To detect paresis of the extremities, a Barre test is performed: the paretic arm, extended forward or raised upward, gradually lowers, the leg raised above the bed also gradually lowers, and the healthy one is held in the given position (Fig. 4.6). A light paresis can be detected by a test for the rhythm of active movements: the patient is asked to pronate and supinate his hands, clench his hands into fists and unclench them, move his legs, as if riding a bicycle; the insufficiency of the strength of the limb is manifested in the fact that it is more likely to get tired, the movements are performed not so quickly and less dexterously than with a healthy limb.

Muscle tone is a reflex muscle tension that provides preparation for performing a movement, maintaining balance and posture, and the ability of a muscle to resist stretching. There are two components of muscle tone: the intrinsic muscle tone, which

depends on the characteristics of the metabolic processes occurring in it, and the neuromuscular tone (reflex), which is caused by muscle stretching, i.e. irritation of proprioreceptors and is determined by the nerve impulses that reach this muscle. The basis of tonic reactions is the stretch reflex, the arc of which closes in the spinal cord. It is this tone that lies in

Rice. 4.6. Barre test.

Paretic leg descends faster

on the basis of various tonic reactions, including antigravitational ones, carried out under conditions of maintaining the connection of muscles with the central nervous system.

Muscle tone is influenced by the spinal (segmental) reflex apparatus, afferent innervation, reticular formation, as well as cervical tonic, including vestibular centers, cerebellum, red nucleus system, basal nuclei, etc.

Muscle tone is assessed by palpation of the muscles: with a decrease in muscle tone, the muscle is flabby, soft, pasty, with increased tone it has a denser texture. However, the determining factor is the study of muscle tone by rhythmic passive movements (flexors and extensors, adductors and abductors, pronators and supinators), performed with maximum relaxation of the subject. Hypotension is called a decrease in muscle tone, atony is its absence. A decrease in muscle tone is accompanied by the appearance of Orshansky's symptom: when lifting up (in a patient lying on his back) a leg unbent at the knee joint, it is overextended in this joint. Hypotension and muscle atony occur with peripheral paralysis or paresis (violation of the efferent section of the reflex arc with damage to the nerve, root, cells of the anterior horn of the spinal cord), damage to the cerebellum, brain stem, striatum and posterior cords of the spinal cord.

Muscle hypertension is the tension felt by the examiner during passive movements. There are spastic and plastic hypertension. Spastic hypertension is an increase in the tone of the flexors and pronators of the arm and the extensor and adductors of the leg due to damage to the pyramidal tract. In spastic hypertension, during repeated movements of the limb, muscle tone does not change or decreases. In spastic hypertension, a “penknife” symptom is observed (an obstruction to passive movement in the initial phase of the study).

Plastic hypertension - a uniform increase in the tone of the muscles, flexors, extensors, pronators and supinators occurs when the pallidonigral system is damaged. In the process of research with plastic hypertension, muscle tone increases, a “gear wheel” symptom is noted (a feeling of jerky, intermittent movement during the study of muscle tone in the limbs).

reflexes

A reflex is a reaction to irritation of receptors in the reflexogenic zone: muscle tendons, skin of a certain area of ​​​​the body

la, mucous membrane, pupil. By the nature of the reflexes, the state of various parts of the nervous system is judged. In the study of reflexes, their level, uniformity, asymmetry are determined; at an elevated level, a reflexogenic zone is noted. When describing reflexes, the following gradations are used: live reflexes; hyporeflexia; hyperreflexia (with an extended reflexogenic zone); areflexia (absence of reflexes). Allocate deep, or proprioceptive (tendon, periosteal, articular), and superficial (skin, mucous membranes) reflexes.

Tendon and periosteal reflexes (Fig. 4.7) are evoked when the hammer is tapped on the tendon or periosteum: the response is manifested by the motor reaction of the corresponding muscles. It is necessary to study the reflexes on the upper and lower extremities in a position favorable for the reflex reaction (lack of muscle tension, average physiological position).

Upper limbs: reflex from the tendon of the biceps muscle of the shoulder (Fig. 4.8) is caused by tapping the hammer on the tendon of this muscle (the patient's arm should be bent at the elbow joint at an angle of about 120 °). In response, the forearm flexes. Reflex arc - sensitive and motor fibers of the musculocutaneous nerves. Closing the arc occurs at the level of segments C v -C vi . The reflex from the tendon of the triceps muscle of the shoulder (Fig. 4.9) is caused by a blow of the hammer on the tendon of this muscle above the olecranon (the patient's arm should be bent at the elbow joint at an angle of 90 °). In response, the forearm extends. Reflex arc: radial nerve, segments C vi -C vii. The radial reflex (carporadial) (Fig. 4.10) is evoked by percussion of the styloid process of the radius (the patient's arm should be bent at the elbow joint at an angle of 90 ° and be in a position between pronation and supination). In response, flexion and pronation of the forearm and flexion of the fingers occur. Reflex arc: fibers of the median, radial and musculocutaneous nerves, C v -C viii .

Lower limbs: knee jerk (Fig. 4.11) is caused by a blow of the hammer on the tendon of the quadriceps muscle. In response, the leg is extended. Reflex arc: femoral nerve, L ii -L iv . When examining the reflex in the supine position, the patient's legs should be bent at the knee joints at an obtuse angle (about 120 °) and the forearm should be supported by the examiner in the area of ​​the popliteal fossa; when examining the reflex in the sitting position, the patient's shins should be at an angle of 120 ° to the hips, or, if the patient does not rest with his feet on the floor, freely

Rice. 4.7. Tendon reflex (diagram). 1 - central gamma path; 2 - central alpha path; 3 - spinal (sensitive) node; 4 - Renshaw cell; 5 - spinal cord; 6 - alphamotoneuron of the spinal cord; 7 - gamma motor neuron of the spinal cord; 8 - alpha efferent nerve; 9 - gamma efferent nerve; 10 - primary afferent nerve of the muscle spindle; 11 - afferent nerve of the tendon; 12 - muscle; 13 - muscle spindle; 14 - nuclear bag; 15 - spindle pole.

The sign "+" (plus) indicates the process of excitation, the sign "-" (minus) - inhibition

Rice. 4.8. Inducing elbow-flexion reflex

Rice. 4.9. Induction of the extensor elbow reflex

but hang over the edge of the seat at an angle of 90 ° to the hips, or one leg of the patient is thrown over the other. If the reflex cannot be evoked, then the Endrashik method is used: the reflex is evoked at the time when the patient stretches the tightly clasped hands to the sides. The heel (Achilles) reflex (Fig. 4.12) is evoked by tapping the Achilles tendon. In response,

Rice. 4.10. Inducing a carpal-beam reflex

dit plantar flexion of the foot as a result of contraction of the calf muscles. In a patient lying on his back, the leg should be bent at the hip, knee and ankle joints at an angle of 90 °. The examiner holds the foot with the left hand, and beats the Achilles tendon with the right hand. In the position of the patient on the stomach, both legs are bent at the knee and ankle joints at an angle of 90 °. The examiner holds the foot or sole with one hand, and strikes with a hammer with the other. The study of the heel reflex can be done by placing the patient on his knees on the couch so that the feet are bent at an angle of 90 °. In a patient sitting on a chair, you can bend the leg at the knee and ankle joints and cause a reflex by tapping on the calcaneal tendon. Reflex arc: tibial nerve, segments S I -S II.

Articular reflexes are evoked by irritation of the receptors of the joints and ligaments on the hands: Mayer - opposition and flexion in the metacarpophalangeal and extension in the interphalangeal articulation of the first finger with forced flexion in the main phalanx of the III and IV fingers. Reflex arc: ulnar and median nerves, segments C VIII -Th I. Leri - flexion of the forearm with forced flexion of the fingers and hand in the supination position. Reflex arc: ulnar and median nerves, segments C VI -Th I.

skin reflexes. Abdominal reflexes (Fig. 4.13) are caused by rapid dashed irritation from the periphery to the center in the corresponding skin zone in the position of the patient lying on his back with legs slightly bent. Manifested by unilateral contraction of the muscles of the anterior abdominal wall. The upper (epigastric) reflex is evoked by stimulation along the edge of the costal arch. Reflex arc - segments Th VII -Th VIII. Medium (mesogastric) - with irritation at the level of the navel. Reflex arc - segments Th IX -Th X . Lower (hypogastric) when applying irritation parallel to the inguinal fold. Reflex arc - ilioinguinal and iliohypogastric nerves, segments Th IX -Th X.

Rice. 4.11. Causing a knee jerk in the patient's sitting position (but) and lying (6)

Rice. 4.12. Causing a calcaneal reflex in the position of the patient on his knees (but) and lying (6)

Rice. 4.13. Inducing abdominal reflexes

The cremaster reflex is evoked by stroke stimulation of the inner surface of the thigh. In response, there is a pulling up of the testicle due to contraction of the muscle that lifts the testicle. Reflex arc - femoral-genital nerve, segments L I -L II. Plantar reflex - plantar flexion of the foot and fingers with dashed irritation of the outer edge of the sole. Reflex arc - tibial nerve, segments L V -S III. Anal reflex - contraction of the external sphincter of the anus with tingling or dashed irritation of the skin around it. It is called in the position of the subject lying on his side with the legs brought to the stomach. Reflex arc - pudendal nerve, segments S III -S V.

Pathological reflexes appear when the pyramidal tract is damaged. Depending on the nature of the response, extensor and flexion reflexes are distinguished.

Pathological extensor reflexes in the lower extremities. The Babinsky reflex (Fig. 4.14) is of the greatest importance - extension of the first toe with dashed irritation of the outer edge of the sole. In children under the age of 2-2.5 years, it is a physiological reflex. Oppenheim reflex (Fig. 4.15) - extension of the first toe in response to the researcher's fingers running along the tibial crest down to the ankle joint. Gordon's reflex (Fig. 4.16) - slow extension of the first toe and fan-shaped spreading of other fingers with compression of the calf muscles. Schaefer reflex (Fig. 4.17) - extension of the first toe with compression of the Achilles tendon.

Flexion pathological reflexes on the lower extremities. The Rossolimo reflex (Fig. 4.18) is most often detected - flexion of the toes with a quick tangential blow to the fingertips. Bekhterev-Mendel reflex (Fig. 4.19) - flexion of the toes when struck with a hammer on its back surface. Zhukovsky reflex (Fig. 4.20) - bend-

Rice. 4.14. Inducing the Babinski reflex (but) and his scheme (b)

bathing of the toes when hit with a hammer on its plantar surface directly under the fingers. Bechterew's reflex (Fig. 4.21) - flexion of the toes when struck with a hammer on the plantar surface of the heel. It should be borne in mind that the Babinsky reflex appears with an acute lesion of the pyramidal system, and the Rossolimo reflex is a late manifestation of spastic paralysis or paresis.

Flexion pathological reflexes on the upper limbs. Tremner's reflex - flexion of the fingers in response to rapid tangential irritations with the fingers of the examiner of the palmar surface of the terminal phalanges of the II-IV fingers of the patient. The Jacobson-Lask reflex is a combined flexion of the forearm and fingers in response to a hammer blow on the styloid process of the radius. Zhukovsky reflex - flexion of the fingers of the hand when struck with a hammer on its palmar surface. Bekhterev's carpal-finger reflex - flexion of the fingers of the hand when tapping with a hammer on the back of the hand.

Pathological protective reflexes, or reflexes of spinal automatism, on the upper and lower extremities - involuntary shortening or lengthening of a paralyzed limb when pricked, pinched, cooled with ether or proprioceptive irritation according to the Bekhterev-Marie-Foy method, when the researcher produces a sharp active flexion of the toes. Protective reflexes are often flexion (involuntary flexion of the leg in the ankle, knee and hip joints). The extensor protective reflex is manifested by involuntary extension

Rice. 4.15. Inducing the Oppenheim reflex

Rice. 4.16. Invoking the Gordon Reflex

Rice. 4.17. Invoking the Schaefer reflex

Rice. 4.18. Invoking the Rossolimo reflex

Rice. 4.19. Calling the Bekhterev-Mendel reflex

Rice. 4.20. Invoking the Zhukovsky reflex

Rice. 4.21. Calling the calcaneal Bekhterev's reflex

I eat legs in the hip, knee joints and plantar flexion of the foot. Cross-protective reflexes - flexion of the irritated leg and extension of the other are usually noted with a combined lesion of the pyramidal and extrapyramidal tracts, mainly at the level of the spinal cord. When describing protective reflexes, the form of the reflex response, the reflexogenic zone, is noted. the reflex evoking area and the intensity of the stimulus.

Neck tonic reflexes occur in response to irritation associated with a change in the position of the head in relation to the body. Magnus-Klein reflex - increased extensor tone in the muscles of the arm and leg, towards which the head is turned with the chin, flexor tone in the muscles of opposite limbs when turning the head; flexion of the head causes an increase in flexor, and extension of the head - extensor tone in the muscles of the limbs.

Gordon's reflex - delaying the lower leg in the extension position when causing a knee jerk. The phenomenon of the foot (Westphal) is the “freezing” of the foot during its passive dorsiflexion. Foix-Thevenard's shin phenomenon (Fig. 4.22) - incomplete extension of the shin in the knee joint in a patient lying on his stomach, after the shin was kept in the position of extreme flexion for some time; manifestation of extrapyramidal rigidity.

Yanishevsky's grasping reflex on the upper limbs - involuntary grasping of objects in contact with the palm; on the lower extremities - increased flexion of the fingers and feet during movement or other irritation of the sole. Distant grasping reflex - an attempt to capture an object shown at a distance; seen in lesions of the frontal lobe.

A sharp increase in tendon reflexes are manifested clonuses- a series of fast rhythmic contractions of a muscle or group of muscles in response to their stretching (Fig. 4.23). Clonus of the foot is caused in a patient lying on his back. The examiner bends the patient's leg in the hip and knee joints, holds it with one hand, and the other

Rice. 4.22. Examination of the postural reflex (shin phenomenon)

Rice. 4.23. Causing clonus of the patella (but) and feet (b)

the goy grabs the foot and, after maximum plantar flexion, jerkily produces a dorsiflexion of the foot. In response, rhythmic clonic movements of the foot occur during the time of stretching of the calcaneal tendon.

Clonus of the patella is caused in a patient lying on his back with straightened legs: fingers I and II grab the top of the patella, pull it up, then sharply shift it in the distal

direction and hold in that position; in response, rhythmic contractions and relaxation of the quadriceps femoris muscle and twitching of the patella appear.

Synkinesia- reflex friendly movement of a limb (or other part of the body), accompanying the voluntary movement of another limb (part of the body). There are physiological and pathological synkinesis. Pathological synkinesis is divided into global, imitation and coordinating.

Global(spastic) - synkinesis of the tone of the flexors of the paralyzed arm and extensors of the leg when trying to move paralyzed limbs, with active movements of healthy limbs, tension of the muscles of the trunk and neck, when coughing or sneezing. Imitation synkinesis - involuntary repetition by paralyzed limbs of voluntary movements of healthy limbs on the other side of the body. coordinating synkinesis - the performance of additional movements by the paretic limbs in the process of a complex purposeful motor act (for example, flexion in the wrist and elbow joints when trying to clench the fingers into a fist).

contractures

Persistent tonic muscle tension, causing limitation of movement in the joint, is called contracture. There are flexion, extensor, pronator contractures; by localization - contractures of the hand, foot; mono-, para-, tri- and quadriplegic; according to the method of manifestation - persistent and unstable in the form of tonic spasms; by the time of occurrence after the development of the pathological process - early and late; in connection with pain - protective-reflex, antalgic; depending on the defeat of various parts of the nervous system - pyramidal (hemiplegic), extrapyramidal, spinal (paraplegic). Late hemiplegic contracture (Wernicke-Mann posture) - bringing the shoulder to the body, flexion of the forearm, flexion and pronation of the hand, extension of the thigh, lower leg and plantar flexion of the foot; when walking, the leg describes a semicircle (Fig. 4.24).

Hormetonia is characterized by periodic tonic spasms, mainly in the flexors of the upper and extensors of the lower extremities, and is characterized by dependence on intero- and exteroceptive stimuli. At the same time, there are pronounced protective reflexes.

Semiotics of movement disorders

There are two main syndromes of damage to the pyramidal tract - due to the involvement of central or peripheral motor neurons in the pathological process. The defeat of the central motor neurons at any level of the cortical-spinal tract causes central (spastic) paralysis, and the defeat of the peripheral motor neuron causes peripheral (flaccid) paralysis.

peripheral paralysis(paresis) occurs when peripheral motor neurons are damaged at any level (the body of a neuron in the anterior horn of the spinal cord or the motor nucleus of the cranial nerve in the brainstem, the anterior root of the spinal cord or the motor root of the cranial nerve, plexus and peripheral nerve). Damage can capture the anterior horns, anterior roots, peripheral nerves. The affected muscles lack both voluntary and reflex activity. Muscles are not only paralyzed, but also hypotonic (muscular hypoor atony). There is an inhibition of tendon and periosteal reflexes (areflexia or hyporeflexia) due to interruption of the monosynaptic arc of the stretch reflex. After a few weeks, atrophy develops, as well as a reaction of degeneration of paralyzed muscles. This indicates that the cells of the anterior horns have a trophic effect on muscle fibers, which is the basis for normal muscle function.

Along with the general features of peripheral paresis, there are features of the clinical picture that allow you to accurately determine where the pathological process is localized: in the anterior horns, roots, plexuses, or in peripheral nerves. When the anterior horn is affected, the muscles innervated from this segment suffer. Often in atrophying

Rice. 4.24. Pose Wernicke-Mann

In muscles, rapid involuntary contractions of individual muscle fibers and their bundles are observed - fibrillar and fascicular twitches, which are the result of irritation by the pathological process of neurons that have not yet died. Since the innervation of the muscles is polysegmental, complete paralysis is observed only when several neighboring segments are affected. The defeat of all the muscles of the limb (monoparesis) is rare, since the cells of the anterior horn, supplying various muscles, are grouped into columns located at some distance from each other. The anterior horns can be involved in the pathological process in acute poliomyelitis, amyotrophic lateral sclerosis, progressive spinal muscular atrophy, syringomyelia, hematomyelia, myelitis, and circulatory disorders of the spinal cord.

With damage to the anterior roots (radiculopathy, sciatica), the clinical picture is similar to that in the defeat of the anterior horn. There is also a segmental distribution of paralysis. Paralysis of radicular origin develops only with the simultaneous defeat of several adjacent roots. Since the defeat of the anterior roots is often caused by pathological processes that simultaneously involve the posterior (sensitive) roots, movement disorders are often combined with sensory disturbances and pain in the innervation zone of the corresponding roots. The cause is degenerative diseases of the spine (osteochondrosis, deforming spondylosis), neoplasms, inflammatory diseases.

Damage to the nerve plexus (plexopathy, plexitis) is manifested by peripheral paralysis of the limb in combination with pain and anesthesia, as well as autonomic disorders in this limb, since the plexus trunks contain motor, sensory and autonomic nerve fibers. Often there are partial lesions of the plexuses. Plexopathy, as a rule, is caused by local traumatic injuries, infectious, toxic effects.

When a mixed peripheral nerve is damaged, peripheral paralysis of the muscles innervated by this nerve occurs (neuropathy, neuritis). Sensitive and vegetative disturbances caused by interruption of afferent and efferent fibers are also possible. Damage to a single nerve is usually associated with mechanical action (compression, acute trauma, ischemia). Simultaneous damage to many peripheral nerves leads to the development of peripheral paresis, most often bilateral, mainly in dis-

tal segments of the extremities (polyneuropathy, polyneuritis). At the same time, motor and autonomic disorders may occur. Patients note paresthesia, pain, a decrease in sensitivity by the type of "socks" or "gloves", trophic skin lesions are detected. The disease is usually caused by intoxication (alcohol, organic solvents, salts of heavy metals), systemic diseases (cancer of internal organs, diabetes mellitus, porphyria, pellagra), exposure to physical factors, etc.

Clarification of the nature, severity and localization of the pathological process is possible with the help of electrophysiological research methods - electromyography, electroneurography.

At central paralysis damage to the motor area of ​​the cerebral cortex or the pyramidal pathway leads to the cessation of the transmission of impulses for the implementation of voluntary movements from this part of the cortex to the anterior horns of the spinal cord. The result is paralysis of the corresponding muscles.

The main symptoms of central paralysis are a decrease in strength in combination with a limitation in the range of active movements (hemi-, para-, tetraparesis; a spastic increase in muscle tone (hypertonicity); an increase in proprioceptive reflexes with an increase in tendon and periosteal reflexes, an expansion of reflexogenic zones, the appearance of clonuses; a decrease or loss of skin reflexes (abdominal, cremasteric, plantar); the appearance of pathological reflexes (Babinsky, Rossolimo, etc.); the appearance of protective reflexes; the occurrence of pathological synkinesis; the absence of a rebirth reaction.

Symptoms may vary depending on the location of the lesion in the central motor neuron. Damage to the precentral gyrus is manifested by a combination of partial motor epileptic seizures (Jacksonian epilepsy) and central paresis (or paralysis) of the opposite limb. Paresis of the leg, as a rule, corresponds to the defeat of the upper third of the gyrus, the hand - its middle third, half of the face and tongue - the lower third. Convulsions, starting in one limb, often move to other parts of the same half of the body. This transition corresponds to the order of location of the motor representation in the precentral gyrus.

Subcortical lesion (crown radiata) is accompanied by contralateral hemiparesis. If the focus is located closer to the lower half of the precentral gyrus, then the arm is more affected, if to the upper - the leg.

The defeat of the internal capsule leads to the development of contralateral hemiplegia. Due to the simultaneous involvement of corticonuclear fibers, central paresis of the contralateral facial and hypoglossal nerves is observed. The defeat of the ascending sensory pathways passing in the internal capsule is accompanied by the development of contralateral hemihypesthesia. In addition, conduction along the optic tract is disturbed with loss of contralateral visual fields. Thus, the lesion of the internal capsule can be clinically described by the "three hemi syndrome" - hemiparesis, hemihypesthesia and hemianopsia on the side opposite to the lesion.

Damage to the brain stem (brain stem, pons, medulla oblongata) is accompanied by damage to the cranial nerves on the side of the focus and hemiplegia on the opposite side - the development of alternating syndromes. When the brain stem is damaged, on the side of the focus there is a lesion of the oculomotor nerve, and on the opposite side - spastic hemiplegia or hemiparesis (Weber's syndrome). Damage to the pons is manifested by the development of alternating syndromes involving the V, VI, and VII cranial nerves. When the pyramids of the medulla oblongata are affected, contralateral hemiparesis is detected, while the bulbar group of cranial nerves can remain intact. If the chiasm of the pyramids is damaged, a rare syndrome of cruciant (alternating) hemiplegia develops (right arm and left leg or vice versa). In the case of a unilateral lesion of the pyramidal tracts in the spinal cord below the level of the lesion, spastic hemiparesis (or monoparesis) is detected, while the cranial nerves remain intact. Bilateral damage to the pyramidal tracts in the spinal cord is accompanied by spastic tetraplegia (paraplegia). At the same time, sensitive and trophic disorders are detected.

For the recognition of focal lesions of the brain in patients in a coma, the symptom of a rotated outward foot is important (Fig. 4.25). On the side opposite the lesion, the foot is turned outward, as a result of which it rests not on the heel, but on the outer surface. In order to determine this symptom, you can use the method of maximum turn of the feet outward - Bogolepov's symptom. On the healthy side, the foot immediately returns to its original position, and the foot on the side of hemiparesis remains turned outward.

It must be borne in mind that if the interruption of the pyramidal tract occurs suddenly, the muscle stretch reflex is suppressed. This means that we-

Rice. 4.25. Foot rotation in hemiplegia

cervical tone, tendon and periosteal reflexes may initially be reduced (diaschisis stage). It may take days or weeks before they recover. When this happens, the muscle spindles will become more sensitive to stretch than before. This is especially evident in the flexors of the arm and extensors of the leg. Gi-

sensitivity of stretch receptors is caused by damage to the extrapyramidal pathways that terminate in the cells of the anterior horns and activate γ-motoneurons innervating intrafusal muscle fibers. As a result, the impulses along the feedback rings that regulate the length of the muscles change so that the flexors of the arm and the extensors of the leg are fixed in the shortest possible state (the position of the minimum length). The patient loses the ability to voluntarily inhibit hyperactive muscles.

4.2. Extrapyramidal system

The term "extrapyramidal system" (Fig. 4.26) refers to subcortical and stem extrapyramidal formations, the motor pathways from which do not pass through the pyramids of the medulla oblongata. The most important source of afferentation for them is the motor cortex of the cerebral hemispheres.

The main elements of the extrapyramidal system are the lenticular nucleus (consists of the pale ball and the shell), the caudate nucleus, the amygdala complex, the subthalamic nucleus, the substantia nigra. The extrapyramidal system includes the reticular formation, the nuclei of the trunk tegmentum, the vestibular nuclei and the lower olive, the red nucleus.

In these structures, impulses are transmitted to intercalary nerve cells and then descend as tegmental, red nuclear, reticular and vestibulo-spinal and other pathways to the motor neurons of the anterior horns of the spinal cord. Through these pathways, the extrapyramidal system influences spinal motor activity. The extrapyramidal system, consisting of projection efferent nerve pathways starting in the cerebral cortex, including the nuclei of the striatum, some

Rice. 4.26. Extrapyramidal system (scheme).

1 - motor area of ​​the large brain (fields 4 and 6) on the left; 2 - cortical pallidar fibers; 3 - frontal region of the cerebral cortex; 4 - striopallidar fibers; 5 - shell; 6 - pale ball; 7 - caudate nucleus; 8 - thalamus; 9 - subthalamic nucleus; 10 - frontal bridge path; 11 - red nuclear-thalamic path; 12 - midbrain; 13 - red core; 14 - black substance; 15 - dentate-thalamic path; 16 - gear-red nuclear path; 17 - superior cerebellar peduncle; 18 - cerebellum; 19 - dentate nucleus; 20 - middle cerebellar peduncle; 21 - lower cerebellar peduncle; 22 - olive; 23 - proprioceptive and vestibular information; 24 - occlusal-spinal, reticular-spinal and red nuclear-spinal path

tory nuclei of the brain stem and cerebellum, regulates movements and muscle tone. It complements the cortical system of voluntary movements. An arbitrary movement becomes prepared, finely “tuned” for execution.

The pyramidal pathway (through the interneurons) and fibers of the extrapyramidal system ultimately occur on anterior horn motor neurons, on α- and γ-cells, and affect them by both activation and inhibition. The pyramidal path begins in the sensorimotor region of the cerebral cortex (fields 4, 1, 2, 3). At the same time, extrapyramidal motor pathways begin in these fields, which include corticostriatal, corticorubral, corticonigral and corticoreticular fibers going to the motor nuclei of the cranial nerves and to the spinal motor nerve cells through the descending chains of neurons.

The extrapyramidal system is phylogenetically older (especially its pallidar part) than the pyramidal system. With the development of the pyramidal system, the extrapyramidal system moves into a subordinate position.

The level of the lower order of this system, the most ancient phylo- and otnogenetically structures - reti-

cular formation of the tegmentum of the brainstem and spinal cord. With the development of the animal world, the paleostriatum (pale ball) began to dominate these structures. Then, in higher mammals, the neostriatum (caudate nucleus and shell) acquired a leading role. As a rule, phylogenetically later centers dominate over earlier ones. This means that in lower animals the supply of innervation of movements belongs to the extrapyramidal system. Fish are a classic example of "pallidar" creatures. In birds, a fairly developed neostriatum appears. In higher animals, the role of the extrapyramidal system remains very important, although as the cerebral cortex forms, phylogenetically older motor centers (paleostriatum and neostriatum) are increasingly controlled by a new motor system - the pyramidal system.

The striatum receives impulses from various areas of the cerebral cortex, primarily from the motor cortex (fields 4 and 6). These afferent fibers, somatotopically organized, run ipsilaterally and are inhibitory in action. The striatum is also reached by another system of afferent fibers coming from the thalamus. From the caudate nucleus and the shell of the lenticular nucleus, the main afferent pathways are sent to the lateral and medial segments of the pale ball. There are connections of the ipsilateral cerebral cortex with the substantia nigra, the red nucleus, the subthalamic nucleus, and the reticular formation.

The caudate nucleus and the shell of the lenticular nucleus have two channels of communication with the black substance. Nigrostriatal dopaminergic neurons have an inhibitory effect on the function of the striatum. At the same time, the GABAergic strionigral pathway has a depressing effect on the function of dopaminergic nigrostriatal neurons. These are closed feedback loops.

A mass of efferent fibers from the striatum passes through the medial segment of the globus pallidus. They form thick bundles of fibers, one of which is called the lenticular loop. Its fibers pass ventromedially around the posterior leg of the internal capsule, heading to the thalamus and hypothalamus, as well as reciprocally to the subthalamic nucleus. After crossing, they connect with the reticular formation of the midbrain; the chain of neurons descending from it forms the reticular-spinal tract (descending reticular system), ending in the cells of the anterior horns of the spinal cord.

The main part of the efferent fibers of the pale ball goes to the thalamus. This is the pallidothalamic bundle, or Trout HI field. Most of it

fibers end in the anterior nuclei of the thalamus, which are projected onto the cortical field 6. The fibers that begin in the dentate nucleus of the cerebellum end in the posterior nucleus of the thalamus, which is projected onto the cortical field 4. In the cortex, the thalamocortical pathways form synapses with corticostriatal neurons and form feedback loops. Reciprocal (coupled) thalamocortical junctions facilitate or inhibit the activity of cortical motor fields.

Semiotics of extrapyramidal disorders

The main signs of extrapyramidal disorders are disorders of muscle tone and involuntary movements. Two groups of main clinical syndromes can be distinguished. One group is a combination of hypokinesis and muscle hypertension, the other is hyperkinesis, in some cases combined with muscle hypotension.

Akinetic-rigid syndrome(syn.: amyostatic, hypokinetic-hypertonic, pallidonigral syndrome). This syndrome in its classical form is found in Parkinson's disease. Clinical manifestations are represented by hypokinesia, rigidity, tremor. With hypokinesia, all mimic and expressive movements slow down sharply (bradykinesia) and are gradually lost. The beginning of a movement, such as walking, switching from one motor act to another, is very difficult. The patient first takes a few short steps; having started the movement, he cannot suddenly stop and takes a few extra steps. This continued activity is called propulsion. Retropulse or lateropulsion is also possible.

The whole gamut of movements turns out to be impoverished (oligokinesia): the body, when walking, is in a fixed position of anteflexion (Fig. 4.27), the hands do not participate in the act of walking (acheirokinesis). All mimic (hypomimia, amimia) and friendly expressive movements are limited or absent. Speech becomes quiet, slightly modulated, monotonous and dysarthric.

Muscle rigidity is noted - a uniform increase in tone in all muscle groups (plastic tone); perhaps "wax" resistance to all passive movements. A symptom of a gear wheel is revealed - in the process of research, the tone of the antagonist muscles decreases stepwise, inconsistently. The head of the lying patient, carefully raised by the examiner, does not fall if it is suddenly released, but gradually lowers. As opposed to spasmodic

paralysis, proprioceptive reflexes are not increased, and pathological reflexes and paresis are absent.

Small-scale, rhythmic tremor of the hands, head, lower jaw has a low frequency (4-8 movements per second). Tremor occurs at rest and is the result of the interaction of muscle agonists and antagonists (antagonistic tremor). It has been described as a "pill rolling" or "coin counting" tremor.

Hyperkinetic-hypotonic syndrome- the appearance of excessive, uncontrolled movements in various muscle groups. There are local hyperkinesis involving individual muscle fibers or muscles, segmental and generalized hyperkinesis. There are fast and slow hyperkinesias, with persistent tonic tension of individual muscles.

Athetosis(Fig. 4.28) is usually caused by damage to the striatum. There are slow worm-like movements with a tendency to hyperextension of the distal parts of the limbs. In addition, there is an irregular increase in muscle tension in agonists and antagonists. As a result, the postures and movements of the patient become pretentious. Voluntary movements are significantly impaired due to the spontaneous occurrence of hyperkinetic movements, which can capture the face, tongue and, thus, cause grimaces with abnormal tongue movements, speech difficulties. Athetosis can be combined with contralateral paresis. It can also be bilateral.

Facial paraspasm- local hyperkinesis, manifested by tonic symmetrical contractions of facial muscles, muscles of the tongue, eyelids. Sometimes he watches

Rice. 4.27. parkinsonism

Rice. 4.28. Athetosis (a-e)

Xia isolated blepharospasm (Fig. 4.29) - an isolated contraction of the circular muscles of the eyes. It is provoked by talking, eating, smiling, intensifies with excitement, bright lighting and disappears in a dream.

Choreic hyperkinesis- short, fast, erratic involuntary twitches in the muscles, causing various movements, sometimes resembling arbitrary ones. First, the distal parts of the limbs are involved, then the proximal ones. Involuntary twitches of the facial muscles cause grimaces. Perhaps the involvement of sound-reproducing muscles with involuntary screams, sighs. In addition to hyperkinesis, there is a decrease in muscle tone.

Spasmodic torticollis(rice.

4.30) and torsion dystonia (Fig.

4.31) are the most common forms of muscular dystonia. In both diseases, the putamen and centromedial nucleus of the thalamus are usually affected, as well as other extrapyramidal nuclei (globus pallidus, substantia nigra, etc.). spastic

torticollis - a tonic disorder, expressed in spastic contractions of the muscles of the cervical region, leading to slow, involuntary turns and tilts of the head. Patients often use compensatory techniques to reduce hyperkinesis, in particular, support the head with a hand. In addition to other muscles of the neck, the sternocleidomastoid and trapezius muscles are especially often involved in the process.

Spasmodic torticollis may be a local form of torsion dystonia or an early symptom of another extrapyramidal disease (encephalitis, Huntington's chorea, hepatocerebral dystrophy).

Rice. 4.29. Blepharospasm

Rice. 4.30. Spasmodic torticollis

Torsion dystonia- involvement in the pathological process of the muscles of the trunk, chest with rotational movements of the trunk and proximal segments of the limbs. They can be so pronounced that without support the patient can neither stand nor walk. Possible idiopathic torsion dystonia or dystonia as a manifestation of encephalitis, Huntington's chorea, Hallervorden-Spatz disease, hepatocerebral dystrophy.

ballistic syndrome(ballismus) is manifested by rapid contractions of the proximal muscles of the limbs, rotational contractions of the axial muscles. More often there is a unilateral form - hemiballismus. With hemiballismus, movements have a large amplitude and strength (“throwing”, sweeping), since very large muscle groups are reduced. The reason is the defeat of the subthalamic nucleus of Lewis and its connections with the lateral segment of the pale ball on the side contralateral to the lesion.

Myoclonic jerks- fast, erratic contractions of individual muscles or different muscle groups. Occur, as a rule, with damage to the area of ​​the red nucleus, inferior olives, dentate nucleus of the cerebellum, less often - with damage to the sensorimotor cortex.

Tiki- fast, stereotypical, sufficiently coordinated muscle contractions (most often - the circular muscles of the eye and other muscles of the face). Complex motor tics are possible - sequences of complex motor acts. There are also simple (smacking, coughing, sobbing) and complex (involuntary

fouling words, obscene language) vocal tics. Tics develop as a result of the loss of the inhibitory effect of the striatum on the underlying neuronal systems (globular pallidus, substantia nigra).

Automated Actions- complex motor acts and other sequential actions that occur without consciousness control. Occur with lesions located in the cerebral hemispheres, destroying the connections of the cortex with the basal nuclei while maintaining their connection with the brain stem; appear in the limbs of the same name with the focus (Fig. 4.32).

Rice. 4.31. Torsion spasm (a-c)

Rice. 4.32. Automated Actions (a, b)

4.3. Cerebellar system

The functions of the cerebellum are to ensure the coordination of movements, the regulation of muscle tone, the coordination of the actions of the muscles of agonists and antagonists, and the maintenance of balance. The cerebellum and brainstem occupy the posterior cranial fossa, delimited from the cerebral hemispheres by the cerebellum. The cerebellum is connected to the brain stem by three pairs of peduncles: the superior cerebellar peduncles connect the cerebellum to the midbrain, the middle peduncles pass into the pons, and the inferior cerebellar peduncles connect the cerebellum to the medulla oblongata.

In structural, functional and phylogenetic terms, archicerebellum, paleocerebellum and neocerebellum are distinguished. Archicerebellum (tuft-nodular zone) is an ancient part of the cerebellum, which consists of a nodule and a piece of the worm, closely related to the vestibular

system. Due to this, the cerebellum is able to synergistically modulate spinal motor impulses, which ensures that balance is maintained regardless of the position of the body or its movements.

The paleocerebellum (old cerebellum) consists of the anterior lobe, simple lobule, and posterior cerebellar body. Afferent fibers enter the paleocerebellum mainly from the same half of the spinal cord through the anterior and posterior spinal cord and from the additional sphenoid nucleus through the sphenocerebellar tract. Efferent impulses from the paleocerebellum modulate the activity of the antigravitational muscles and provide sufficient muscle tone for upright standing and walking upright.

The neocerebellum (new cerebellum) consists of the vermis and the region of the hemispheres located between the first and posterior lateral fissure. This is the largest part of the cerebellum. Its development is closely related to the development of the cerebral cortex and the performance of fine, well-coordinated movements. Depending on the main sources of afferentation, these areas of the cerebellum can be characterized as vestibulocerebellum, spinocerebellum, and pontocerebellum.

Each hemisphere of the cerebellum has 4 pairs of nuclei: the nucleus of the tent, spherical, corky and dentate (Fig. 4.33). The first three nuclei are located in the lid of the IV ventricle. The core of the tent is phylogenetically the oldest and is related to archicerebellum. Its efferent fibers go through the lower cerebellar peduncles to the vestibular nuclei. The spherical and cork-shaped nuclei are connected with the adjacent black

Rice. 4.33. Cerebellar nuclei and their connections (diagram).

1 - cerebral cortex; 2 - ventrolateral nucleus of the thalamus; 3 - red core; 4 - the core of the tent; 5 - spherical nucleus; 6 - cork-like nucleus; 7 - dentate nucleus; 8 - dentate-red nuclear and dentate-thalamic pathways; 9 - vestibulo-cerebellar path; 10 - paths from the cerebellar vermis (the core of the tent) to the thin and wedge-shaped nuclei, the lower olive; 11 - anterior spinal cerebellar path; 12 - posterior spinal cerebellar path

the whole area of ​​the paleocerebellum. Their efferent fibers go to the contralateral red nuclei through the superior cerebellar peduncles.

The dentate nucleus is the largest and is located in the central part of the white matter of the cerebellar hemispheres. It receives impulses from the Purkinje cells of the cortex of the entire neocerebellum and part of the paleocerebellum. The efferent fibers go through the superior cerebellar peduncles and pass to the opposite side to the border of the pons and midbrain. Their bulk terminates in the contralateral red nucleus and the ventrolateral nucleus of the thalamus. Fibers from the thalamus are sent to the motor cortex (fields 4 and 6).

The cerebellum receives information from receptors embedded in muscles, tendons, articular bags and deep tissues along the anterior and posterior spinal tracts (Fig. 4.34). The peripheral processes of the cells of the spinal ganglion extend from the muscle spindles to the Golgi-Mazzoni bodies, and the central processes of these cells through the back

Rice. 4.34. Ways of proprioceptive sensitivity of the cerebellum (scheme). 1 - receptors; 2 - posterior cord; 3 - anterior spinal cerebellar path (non-crossed part); 4 - posterior spinal-cerebellar path; 5 - spinal path; 6 - anterior spinal cerebellar path (crossed part); 7 - olivocerebellar path; 8 - lower cerebellar peduncle; 9 - superior cerebellar peduncle; 10 - to the cerebellum; 11 - medial loop; 12 - thalamus; 13 - the third neuron (deep sensitivity); 14 - cerebral cortex

roots enter the spinal cord and split into several collaterals. A significant part of the collaterals connects to the neurons of the Clark-Stilling nucleus, located in the medial part of the base of the posterior horn and extending along the length of the spinal cord from C VII to L II. These cells represent the second neuron. Their axons, which are fast-conducting fibers, create the posterior spinal tract (Flexiga). They rise ipsilaterally in the outer sections of the lateral cords, which, having passed through the peduncle, enter the cerebellum through its lower peduncle.

Some of the fibers emerging from the Clark-Stilling nucleus pass through the anterior white commissure to the opposite side and form the anterior spinal cerebellar tract (Govers). As part of the anterior peripheral part of the lateral cords, it rises to the tegmentum of the medulla oblongata and the bridge; reaching the midbrain, in the upper medullary sail returns to the side of the same name and enters the cerebellum through its upper legs. On the way to the cerebellum, the fibers undergo a second decussation.

In addition, part of the collaterals of the fibers that came from the proprioreceptors in the spinal cord is sent to the large α-motoneurons of the anterior horns, forming the afferent link of the monosynaptic reflex arc.

The cerebellum has connections with other parts of the nervous system. Afferent pathways pass through the lower cerebellar peduncles (rope bodies) from:

1) vestibular nuclei (vestibulocerebellar tract, ending in the flocculent-nodular zone associated with the core of the tent);

2) inferior olives (olivocerebellar pathway, starting in the contralateral olives and ending on the Purkinje cells of the cerebellum);

3) spinal nodes of the same side (posterior spinal cord);

4) reticular formation of the brain stem (reticular-cerebellar);

5) an additional sphenoid nucleus, the fibers from which are attached to the posterior spinal cerebellar tract.

The efferent cerebellobulbar pathway passes through the inferior cerebellar peduncles to the vestibular nuclei. Its fibers represent the efferent part of the vestibulocerebellar modulating feedback loop, through which the cerebellum influences the state of the spinal cord through the predvernospinal tract and the medial longitudinal bundle.

The cerebellum receives information from the cerebral cortex. Fibers from the cortex of the frontal, parietal, temporal, and occipital lobes are sent to the pons of the brain, forming the cortico-cerebellopontine pathways. Fronto-bridge fibers are localized in the anterior leg of the internal capsule. In the midbrain, they occupy the medial quarter of the cerebral peduncles near the interpeduncular fossa. Fibers coming from the parietal, temporal, and occipital lobes of the cortex pass through the posterior part of the posterior crus of the internal capsule and the posterolateral part of the cerebral peduncles. All cortical-bridge fibers form synapses with neurons at the base of the brain bridge, where the bodies of the second neurons are located, sending axons to the contralateral cerebellar cortex, entering it through the middle cerebellar peduncles (cortical-pontine cerebellar pathway).

The superior cerebellar peduncles contain efferent fibers originating in the neurons of the cerebellar nuclei. The bulk of the fibers go to the contralateral red nucleus (Forel's cross), some of them - to the thalamus, the reticular formation and the brain stem. The fibers from the red nucleus make a second decussation (Wernekinka) in the tire, form the cerebellar-red-nuclear-spinal (dentorubro-spinal) path, heading to the anterior horns of the same half of the spinal cord. In the spinal cord, this path is located in the lateral columns.

The thalamocortical fibers reach the cerebral cortex, from which the cortical-pontine fibers descend, thus completing an important feedback loop from the cerebral cortex to the pontine nuclei, the cerebellar cortex, the dentate nucleus, and from there back to the thalamus and cerebral cortex. An additional loop of feedback goes from the red nucleus to the inferior olives through the central tegmental pathway, from there to the cerebellar cortex, the dentate nucleus, back to the red nucleus. Thus, the cerebellum indirectly modulates the motor activity of the spinal cord through its connections with the red nucleus and the reticular formation, from which the descending red nuclear-spinal and reticular-spinal tracts begin. Due to the double decussation of fibers in this system, the cerebellum has an ipsilateral effect on the striated muscles.

All impulses arriving in the cerebellum reach its cortex, undergo processing and multiple recoding due to multiple switching of neural circuits in the cortex and nuclei of the cerebellum. Due to this, and also due to the close connections of the cerebellum with various structures of the brain and spinal cord, it performs its functions relatively independently of the cerebral cortex.

Research methodology

Examine coordination, smoothness, clarity and friendliness of movements, muscle tone. Movement coordination is a finely differentiated successive participation of a number of muscle groups in any motor act. Movement coordination is carried out on the basis of information received from proprioreceptors. Violation of coordination of movements is manifested by ataxia - the loss of the ability to perform purposeful differentiated movements with preserved muscle strength. There are dynamic ataxia (impaired performance of voluntary movements of the limbs, especially the upper ones), static (impaired ability to maintain balance in standing and sitting positions) and static-locomotor (disorders of standing and walking). Cerebellar ataxia develops with preserved deep sensitivity and can be dynamic or static.

Tests for the detection of dynamic ataxia.Finger-nose test(Fig. 4.35): the patient, sitting or standing with arms outstretched in front of him, is asked to touch the tip of his nose with his index finger with his eyes closed. Heel-knee test(Fig. 4.36): the patient, lying on his back, is offered with his eyes closed to get the heel of one leg on the knee of the other and hold the heel down the shin of the other leg. Finger-finger test: the patient is offered to touch the tips of the fingers of the examiner, who is sitting opposite, with the tips of his index fingers. First, the patient performs tests with his eyes open, then with his eyes closed. Cerebellar ataxia is not aggravated by closing the eyes, in contrast to ataxia caused by damage to the posterior funiculi of the spinal cord. Need to install

Rice. 4.35. Finger-nose test

Fig.4.36. Heel-knee test

whether the patient accurately hits the intended target (whether there is a miss or miss) and whether there is an intentional tremor.

Tests for the detection of static and static-locomotor ataxia: the patient walks, legs wide apart, staggering from side to side and deviating from the line of walking - “drunk gait” (Fig. 4.37), cannot stand, deviating to the side.

Romberg test(Fig. 4.38): the patient is asked to stand with his eyes closed, moving his toes and heels, and pay attention to which way the torso deviates. There are several options for the Romberg test:

1) the patient stands with his arms extended forward; the deviation of the torso increases if the patient stands with his eyes closed, his arms extended forward and his legs placed one in front of the other in a straight line;

2) the patient stands with his eyes closed and his head thrown back, while the deviation of the body is more pronounced. Deviation to the side, and in severe cases - and a fall when walking, performing the Romberg test is observed in the direction of the cerebellum lesion.

Violation of smoothness, clarity, friendliness of movements is manifested in tests to identify dysmetria (hypermetry). Dysmetria - disproportion of movements. The movement has an excessive amplitude, ends too late, is carried out impetuously, with excessive speed. First reception: the patient is offered to take objects of various sizes. He cannot pre-arrange his fingers according to the volume of the object to be taken. If the patient is offered a small object, he spreads his fingers too wide and closes them much later than required. The second reception: the patient is offered to stretch his arms forward with palms up and, at the command of the doctor, simultaneously rotate his hands with palms up and down. On the affected side, movements are made more slowly and with excessive amplitude, i.e. revealed adiadochokinesis.

Other samples.Asynergy Babinsky(Fig. 4.39). The patient is offered to sit down from a supine position with arms crossed on the chest. With damage to the cerebellum, it is not possible to sit down without the help of hands, while the patient makes a number of auxiliary movements to the side, raises both legs due to discoordination of movements.

Schilder's test. The patient is offered to stretch out his hands in front of him, closing his eyes, raise one hand vertically upwards, and then lower it to the level of the other hand and repeat the test with the other hand. With damage to the cerebellum, it is impossible to accurately perform the test, the raised hand will fall below the outstretched one.

Rice. 4.37. Patient with atactic gait (but), uneven handwriting and macrography (b)

Rice. 4.38. Romberg test

Rice. 4.39. Asynergy Babinsky

When the cerebellum is damaged, it appears intentional trembling(tremor), when performing arbitrary purposeful movements, it intensifies as it approaches the object as close as possible (for example, when performing a finger-to-nose test, as the finger approaches the nose, the tremor increases).

Violations of the coordination of fine movements and trembling are also manifested by handwriting disorder. The handwriting becomes uneven, the lines zigzag, some letters are too small, others, on the contrary, are large (megalography).

Myoclonus- rapid clonic twitching of muscles or their individual bundles, in particular the muscles of the tongue, pharynx, soft palate, occur when stem formations and their connections with the cerebellum are involved in the pathological process due to a violation of the system of connections dentate nuclei - red nuclei - lower olives.

The speech of patients with cerebellar damage becomes slow, stretched, individual syllables are pronounced louder than others (they become stressed). This speech is called scanned.

nystagmus- involuntary rhythmic biphasic (with fast and slow phases) movements of the eyeballs in case of damage to the cerebellum. As a rule, nystagmus has a horizontal orientation.

Hypotension muscle is manifested by lethargy, muscle flabbiness, excessive excursion in the joints. Tendon reflexes may be reduced. Hypotension can be manifested by a symptom of the absence of a reverse impulse: the patient holds his arm in front of him, bending it at the elbow joint, in which he is resisted. With a sudden cessation of resistance, the patient's hand hits the chest with force. In a healthy person, this does not happen, since antagonists quickly come into action - the extensors of the forearm (reverse push). Hypotension is also due to pendulum reflexes: when examining the knee reflex in the patient's sitting position with the lower legs hanging freely from the couch after a hammer blow, several rocking movements of the lower leg are observed.

Change in postural reflexes is also one of the symptoms of damage to the cerebellum. Doinikov's finger phenomenon: if a sitting patient is asked to hold the hands in supination position with spread fingers (kneeling position), then on the side of the cerebellar lesion, flexion of the fingers and pronation of the hand occur.

Underestimation of the severity of the subject, held by the hand is also a kind of symptom on the side of the cerebellar lesion.

Semiotics of cerebellar disorders With the defeat of the worm, there is an imbalance and instability when standing (astasia) and walking (abasia), ataxia of the body, static disturbance, the patient falling forward or backward.

Due to the commonality of the functions of paleocerebellum and neocerebellum, their defeat causes a single clinical picture. In this regard, in many cases it is impossible to consider one or another clinical symptomatology as a manifestation of a lesion of a limited area of ​​the cerebellum.

The defeat of the cerebellar hemispheres leads to a violation of the performance of locomotor tests (finger-nose, calcaneal-knee), intentional tremor on the side of the lesion, muscle hypotension. Damage to the cerebellar peduncle is accompanied by the development of clinical symptoms due to damage to the corresponding connections. With damage to the lower legs, nystagmus, myoclonus of the soft palate are observed, with damage to the middle legs - a violation of locomotor tests, with damage to the upper legs - the appearance of choreoathetosis, rubral tremor.

Neurology and neurosurgery Evgeny Ivanovich Gusev

3.1. pyramid system

3.1. pyramid system

There are two main types of movements: involuntary And arbitrary.

Involuntary include simple automatic movements carried out by the segmental apparatus of the spinal cord and brain stem in the form of a simple reflex act. Arbitrary purposeful movements are acts of human motor behavior. Special voluntary movements (behavioral, labor, etc.) are carried out with the leading participation of the cerebral cortex, as well as the extrapyramidal system and the segmental apparatus of the spinal cord. In humans and higher animals, the implementation of voluntary movements is associated with the pyramidal system. In this case, the conduction of an impulse from the cerebral cortex to the muscle occurs along a chain consisting of two neurons: central and peripheral.

Central motor neuron. Voluntary muscle movements occur due to impulses traveling along long nerve fibers from the cerebral cortex to the cells of the anterior horns of the spinal cord. These fibers form the motor ( cortical-spinal), or pyramidal, way. They are axons of neurons located in the precentral gyrus, in cytoarchitectonic area 4. This area is a narrow area that stretches along the central fissure from the lateral (or Sylvian) groove to the anterior part of the paracentral lobule on the medial surface of the hemisphere, parallel to the sensory area of ​​the postcentral gyrus cortex .

The neurons that innervate the pharynx and larynx are located in the lower part of the precentral gyrus. Next in ascending order are the neurons that innervate the face, arm, torso, and leg. Thus, all parts of the human body are projected in the precentral gyrus, as it were, upside down. Motor neurons are located not only in field 4, they are also found in neighboring cortical fields. At the same time, the vast majority of them are occupied by the 5th cortical layer of the 4th field. They are "responsible" for precise, targeted single movements. These neurons also include Betz giant pyramidal cells, which have axons with a thick myelin sheath. These fast-conducting fibers make up only 3.4-4% of all fibers of the pyramidal tract. Most of the pyramidal tract fibers originate from small pyramidal, or fusiform (fusiform) cells in motor fields 4 and 6. Field 4 cells give about 40% of the pyramidal tract fibers, the rest originate from cells of other fields of the sensorimotor zone.

Field 4 motor neurons control fine voluntary movements of the skeletal muscles of the opposite half of the body, since most pyramidal fibers pass to the opposite side in the lower part of the medulla oblongata.

The impulses of the pyramidal cells of the motor cortex follow two paths. One - the cortical-nuclear pathway - ends in the nuclei of the cranial nerves, the second, more powerful, cortical-spinal - switches in the anterior horn of the spinal cord on the intercalary neurons, which in turn terminate in the large motor neurons of the anterior horns. These cells transmit impulses through the anterior roots and peripheral nerves to the motor end plates of the skeletal muscles.

When the fibers of the pyramidal tract leave the motor cortex, they pass through the corona radiata of the white matter of the brain and converge towards the posterior leg of the internal capsule. In somatotopic order, they pass through the internal capsule (its knee and the anterior two-thirds of the posterior thigh) and go to the middle part of the legs of the brain, descend through each half of the base of the bridge, being surrounded by numerous nerve cells of the nuclei of the bridge and fibers of various systems. At the level of the pontomedullary articulation, the pyramidal pathway becomes visible from the outside, its fibers forming elongated pyramids on either side of the midline of the medulla oblongata (hence its name). In the lower part of the medulla oblongata, 80-85% of the fibers of each pyramidal tract pass to the opposite side at the intersection of the pyramids and form lateral pyramidal tract. The remaining fibers continue to descend uncrossed in the anterior cords as anterior pyramidal tract. These fibers cross at the segmental level through the anterior commissure of the spinal cord. In the cervical and thoracic parts of the spinal cord, some fibers connect with the cells of the anterior horn of their side, so that the muscles of the neck and trunk receive cortical innervation from both sides.

Crossed fibers descend as part of the lateral pyramidal tract in the lateral cords. About 90% of the fibers form synapses with interneurons, which in turn connect with large alpha and gamma neurons of the anterior horn of the spinal cord.

The fibers that form cortical-nuclear pathway, are sent to the motor nuclei (V, VII, IX, X, XI, XII) of the cranial nerves and provide voluntary innervation of the facial and oral muscles.

Noteworthy is another bundle of fibers, starting in the "eye" field 8, and not in the precentral gyrus. The impulses going along this bundle provide friendly movements of the eyeballs in the opposite direction. The fibers of this bundle at the level of the radiant crown join the pyramidal pathway. Then they pass more ventrally in the posterior crus of the internal capsule, turn caudally and go to the nuclei of the III, IV, VI cranial nerves.

Peripheral motor neuron. Fibers of the pyramidal tract and various extrapyramidal tracts (reticular, tegmental, vestibulo, red nuclear-spinal, etc.) and afferent fibers entering the spinal cord through the posterior roots terminate on the bodies or dendrites of large and small alpha and gamma cells (directly or through intercalary, associative or commissural neurons of the internal neuronal apparatus of the spinal cord) In contrast to the pseudo-unipolar neurons of the spinal nodes, the neurons of the anterior horns are multipolar. Their dendrites have multiple synaptic connections with various afferent and efferent systems. Some of them are facilitating, others are inhibitory in their action. In the anterior horns, motor neurons form groups organized in columns and not divided into segments. There is a certain somatotopic order in these columns. In the cervical part, the lateral motor neurons of the anterior horn innervate the hand and arm, and the motor neurons of the medial columns innervate the muscles of the neck and chest. In the lumbar region, the neurons innervating the foot and leg are also located laterally in the anterior horn, while those innervating the trunk are medial. The axons of the anterior horn cells exit the spinal cord ventrally as radicular fibers, which gather in segments to form the anterior roots. Each anterior root connects to the posterior root distally to the spinal nodes and together they form the spinal nerve. Thus, each segment of the spinal cord has its own pair of spinal nerves.

The composition of the nerves also includes efferent and afferent fibers emanating from the lateral horns of the spinal gray matter.

Well myelinated, fast-conducting axons of large alpha cells run directly to the striated muscle.

In addition to large and small alpha motor neurons, the anterior horns contain numerous gamma motor neurons. Among the intercalary neurons of the anterior horns, Renshaw cells, which inhibit the action of large motor neurons, should be noted. Large alpha cells with a thick and fast-conducting axon carry out rapid muscle contractions. Small alpha cells with a thinner axon perform a tonic function. Gamma cells with a thin and slow-conducting axon innervate the proprioceptors of the muscle spindle. Large alpha cells are associated with giant cells in the cerebral cortex. Small alpha cells have a connection with the extrapyramidal system. Through gamma cells, the state of muscle proprioceptors is regulated. Among the various muscle receptors, the neuromuscular spindles are the most important.

afferent fibers called ring-spiral, or primary, endings, have a fairly thick myelin coating and are fast-conducting fibers.

Many muscle spindles have not only primary but also secondary endings. These endings also respond to stretch stimuli. Their action potential propagates in the central direction along thin fibers communicating with intercalary neurons responsible for the reciprocal actions of the corresponding antagonist muscles. Only a small number of proprioceptive impulses reach the cerebral cortex, most are transmitted through feedback loops and do not reach the cortical level. These are the elements of reflexes that serve as the basis for voluntary and other movements, as well as static reflexes that oppose gravity.

Extrafusal fibers in a relaxed state have a constant length. When the muscle is stretched, the spindle is stretched. The ring-spiral endings respond to stretching by generating an action potential, which is transmitted to the large motor neuron along fast-conducting afferent fibers, and then again along fast-conducting thick efferent fibers - extrafusal muscles. The muscle contracts, its original length is restored. Any stretching of the muscle activates this mechanism. Percussion along the tendon of a muscle causes stretching of this muscle. The spindles react immediately. When the impulse reaches the motor neurons of the anterior horn of the spinal cord, they react by causing a short contraction. This monosynaptic transmission is the basis for all proprioceptive reflexes. The reflex arc covers no more than 1-2 segments of the spinal cord, which is of great importance in determining the localization of the lesion.

Gamma neurons are under the influence of fibers descending from the motor neurons of the CNS as part of such pathways as pyramidal, reticular-spinal, vestibulo-spinal. The efferent influences of gamma fibers make it possible to finely regulate voluntary movements and provide the ability to regulate the strength of the response of receptors to stretch. This is called the gamma-neuron-spindle system.

Research methodology. Inspection, palpation and measurement of muscle volume are carried out, the volume of active and passive movements, muscle strength, muscle tone, rhythm of active movements and reflexes are determined. Electrophysiological methods are used to identify the nature and localization of movement disorders, as well as clinically insignificant symptoms.

The study of motor function begins with an examination of the muscles. Attention is drawn to the presence of atrophy or hypertrophy. By measuring the volume of the muscles of the limb with a centimeter, it is possible to identify the severity of trophic disorders. When examining some patients, fibrillar and fascicular twitches are noted. With the help of palpation, you can determine the configuration of the muscles, their tension.

active movements are checked sequentially in all joints and performed by the subject. They may be absent or limited in scope and weakened in strength. The complete absence of active movements is called paralysis, the restriction of movements or the weakening of their strength is called paresis. Paralysis or paresis of one limb is called monoplegia or monoparesis. Paralysis or paresis of both arms is called upper paraplegia or paraparesis, paralysis or paraparesis of the legs is called lower paraplegia or paraparesis. Paralysis or paresis of two limbs of the same name is called hemiplegia or hemiparesis, paralysis of three limbs - triplegia, paralysis of four limbs - quadriplegia or tetraplegia.

Passive movements are determined with complete relaxation of the muscles of the subject, which makes it possible to exclude a local process (for example, changes in the joints), which limits active movements. Along with this, the definition of passive movements is the main method for studying muscle tone.

Investigate the volume of passive movements in the joints of the upper limb: shoulder, elbow, wrist (flexion and extension, pronation and supination), finger movements (flexion, extension, abduction, adduction, opposition of the first finger to the little finger), passive movements in the joints of the lower extremities: hip, knee, ankle (flexion and extension, rotation outward and inward), flexion and extension of the fingers.

muscle strength is determined consistently in all groups with active resistance of the patient. For example, when examining the strength of the muscles of the shoulder girdle, the patient is asked to raise his arm to a horizontal level, resisting the examiner's attempt to lower his arm; then they offer to raise both hands above the horizontal line and hold them, offering resistance. To determine the strength of the shoulder muscles, the patient is asked to bend the arm at the elbow joint, and the examiner tries to straighten it; the strength of the abductors and adductors of the shoulder is also examined. To study the strength of the muscles of the forearm, the patient is given the task to perform pronation, and then supination, flexion and extension of the hand with resistance during the movement. To determine the strength of the muscles of the fingers, the patient is offered to make a “ring” of the first finger and each of the others, and the examiner tries to break it. They check the strength when the V finger is abducted from the IV and the other fingers are brought together, when the hands are clenched into a fist. The strength of the muscles of the pelvic girdle and thigh is examined when asked to raise, lower, adduct and abduct the thigh, while providing resistance. The strength of the thigh muscles is examined, inviting the patient to bend and straighten the leg at the knee joint. The strength of the calf muscles is checked as follows: the patient is asked to bend the foot, and the examiner keeps it extended; then the task is given to unbend the foot bent at the ankle joint, overcoming the resistance of the examiner. The strength of the muscles of the toes is also examined when the examiner tries to bend and unbend the fingers and separately bend and unbend the first finger.

To detect paresis of the extremities, a Barre test is performed: the paretic arm, extended forward or raised up, gradually lowers, the leg raised above the bed also gradually lowers, while the healthy one is held in the given position. With mild paresis, one has to resort to a test for the rhythm of active movements; pronate and supinate hands, clench hands into fists and unclench them, move legs like on a bicycle; the insufficiency of the strength of the limb is manifested in the fact that it is more likely to get tired, the movements are performed not so quickly and less dexterously than with a healthy limb. The strength of the hands is measured with a dynamometer.

Muscle tone- reflex muscle tension, which provides preparation for movement, maintaining balance and posture, the ability of the muscle to resist stretching. There are two components of muscle tone: the muscle's own tone, which depends on the characteristics of the metabolic processes occurring in it, and neuromuscular tone (reflex), reflex tone is most often caused by muscle stretching, i.e. irritation of proprioreceptors, determined by the nature of the nerve impulses that reach this muscle. It is this tone that underlies various tonic reactions, including antigravitational ones, carried out under conditions of maintaining the connection of muscles with the central nervous system.

The basis of tonic reactions is the stretch reflex, the closure of which occurs in the spinal cord.

Muscle tone is influenced by the spinal (segmental) reflex apparatus, afferent innervation, reticular formation, as well as cervical tonic, including vestibular centers, cerebellum, red nucleus system, basal nuclei, etc.

The state of muscle tone is assessed during examination and palpation of the muscles: with a decrease in muscle tone, the muscle is flabby, soft, pasty. with increased tone, it has a denser texture. However, the determining factor is the study of muscle tone through passive movements (flexors and extensors, adductors and abductors, pronators and supinators). Hypotension is a decrease in muscle tone, atony is its absence. A decrease in muscle tone can be detected when examining Orshansky's symptom: when lifting up (in a patient lying on his back) a leg extended at the knee joint, its overextension in this joint is revealed. Hypotension and muscle atony occur with peripheral paralysis or paresis (violation of the efferent section of the reflex arc with damage to the nerve, root, cells of the anterior horn of the spinal cord), damage to the cerebellum, brain stem, striatum and posterior cords of the spinal cord. Muscle hypertension is the tension felt by the examiner during passive movements. There are spastic and plastic hypertension. Spastic hypertension - an increase in the tone of the flexors and pronators of the arm and extensor and adductors of the leg (with damage to the pyramidal tract). With spastic hypertension, there is a symptom of a “penknife” (an obstacle to passive movement in the initial phase of the study), with plastic hypertension, a symptom of a “cog wheel” (feeling of tremors during the study of muscle tone in the limbs). Plastic hypertension is a uniform increase in the tone of muscles, flexors, extensors, pronators and supinators, which occurs when the pallidonigral system is damaged.

reflexes. A reflex is a reaction that occurs in response to irritation of receptors in the reflexogenic zone: muscle tendons, skin of a certain part of the body, mucous membrane, pupil. By the nature of the reflexes, the state of various parts of the nervous system is judged. In the study of reflexes, their level, uniformity, asymmetry are determined: at an increased level, a reflexogenic zone is noted. When describing reflexes, the following gradations are used: 1) live reflexes; 2) hyporeflexia; 3) hyperreflexia (with an extended reflex zone); 4) areflexia (absence of reflexes). Reflexes can be deep, or proprioceptive (tendon, periosteal, articular), and superficial (skin, mucous membranes).

Tendon and periosteal reflexes are evoked by percussion with a hammer on the tendon or periosteum: the response is manifested by the motor reaction of the corresponding muscles. To obtain tendon and periosteal reflexes on the upper and lower extremities, it is necessary to call them in an appropriate position favorable for the reflex reaction (lack of muscle tension, average physiological position).

Upper limbs. Biceps tendon reflex caused by a hammer blow on the tendon of this muscle (the patient's arm should be bent at the elbow joint at an angle of about 120 °, without tension). In response, the forearm flexes. Reflex arc: sensory and motor fibers of the musculocutaneous nerve, CV-CVI. Triceps tendon reflex caused by a blow of the hammer on the tendon of this muscle above the olecranon (the patient's arm should be bent at the elbow joint almost at an angle of 90 °). In response, the forearm extends. Reflex arc: radial nerve, СVI-СVII. Beam reflex caused by percussion of the styloid process of the radius (the patient's arm should be bent at the elbow joint at an angle of 90 ° and be in a position between pronation and supination). In response, flexion and pronation of the forearm and flexion of the fingers occur. Reflex arc: fibers of the median, radial and musculocutaneous nerves, CV-CVIII.

lower limbs. knee jerk caused by hammer blow on the tendon of the quadriceps muscle. In response, the leg is extended. Reflex arc: femoral nerve, LII-LIV. When examining the reflex in a horizontal position, the patient's legs should be bent at the knee joints at an obtuse angle (about 120 °) and lie freely on the examiner's left forearm; when examining the reflex in the sitting position, the patient's legs should be at an angle of 120 ° to the hips or, if the patient does not rest with his feet on the floor, freely hang over the edge of the seat at an angle of 90 ° to the hips or one leg of the patient is thrown over the other. If the reflex cannot be evoked, then the Endrashik method is used: the reflex is evoked at the time when the patient pulls towards the hand with tightly clasped fingers. Calcaneal (Achilles) reflex caused by percussion on the calcaneal tendon. In response, plantar flexion of the foot occurs as a result of contraction of the calf muscles. Reflex arc: tibial nerve, SI-SII. In a lying patient, the leg should be bent at the hip and knee joints, the foot at the ankle joint at an angle of 90 °. The examiner holds the foot with the left hand, and the calcaneal tendon is percussed with the right hand. In the position of the patient on the stomach, both legs are bent at the knee and ankle joints at an angle of 90 °. The examiner holds the foot or sole with one hand, and strikes with a hammer with the other. The reflex is caused by a short blow to the heel tendon or sole. The study of the heel reflex can be done by placing the patient on his knees on the couch so that the feet are bent at an angle of 90 °. In a patient sitting on a chair, you can bend the leg at the knee and ankle joints and cause a reflex by percussing the calcaneal tendon.

Articular reflexes are caused by irritation of the receptors of the joints and ligaments on the hands. 1. Mayer - opposition and flexion in the metacarpophalangeal and extension in the interphalangeal articulation of the first finger with forced flexion in the main phalanx of the III and IV fingers. Reflex arc: ulnar and median nerves, СVII-ThI. 2. Leri - flexion of the forearm with forced flexion of the fingers and the hand in the supination position, reflex arc: ulnar and median nerves, CVI-ThI.

Skin reflexes are caused by stroke stimulation with the handle of the neurological malleus in the corresponding skin zone in the position of the patient on his back with slightly bent legs. Abdominal reflexes: upper (epigastric) is caused by irritation of the abdominal skin along the lower edge of the costal arch. Reflex arc: intercostal nerves, ThVII-ThVIII; medium (mesogastric) - with irritation of the skin of the abdomen at the level of the navel. Reflex arc: intercostal nerves, ThIX-ThX; lower (hypogastric) - with skin irritation parallel to the inguinal fold. Reflex arc: ilio-hypogastric and ilio-inguinal nerves, ThXI-ThXII; there is a contraction of the abdominal muscles at the appropriate level and the deviation of the navel in the direction of irritation. The cremaster reflex is triggered by stimulation of the inner thigh. In response, the testicle is pulled up due to the contraction of the muscle that lifts the testicle, the reflex arc: the femoral-genital nerve, LI-LII. Plantar reflex - plantar flexion of the foot and fingers with dashed irritation of the outer edge of the sole. Reflex arc: tibial nerve, LV-SII. Anal reflex - contraction of the external sphincter of the anus with tingling or dashed irritation of the skin around it. Called in the position of the subject on the side with the legs brought to the stomach. Reflex arc: pudendal nerve, SIII-SV.

Pathological reflexes . Pathological reflexes appear when the pyramidal tract is damaged, when spinal automatisms are disturbed. Pathological reflexes, depending on the reflex response, are divided into extensor and flexion.

Pathological extensor reflexes on the lower extremities. The Babinsky reflex is of the greatest importance - extension of the first toe with dashed irritation of the skin of the outer edge of the sole, in children under 2-2.5 years old - a physiological reflex. Oppenheim reflex - extension of the first toe in response to running fingers along the tibial crest down to the ankle joint. Gordon's reflex - slow extension of the first toe and fan-shaped divergence of other fingers during compression of the calf muscles. Schaefer's reflex - extension of the first toe with compression of the calcaneal tendon.

Flexion pathological reflexes on the lower extremities. The most important is the Rossolimo reflex - flexion of the toes with a quick tangential blow to the balls of the fingers. Bekhterev-Mendel reflex - flexion of the toes when hit with a hammer on its back surface. Zhukovsky reflex - flexion of the toes when struck with a hammer on its plantar surface directly under the fingers. Ankylosing spondylitis reflex - flexion of the toes when struck with a hammer on the plantar surface of the heel. It should be borne in mind that the Babinski reflex appears with an acute lesion of the pyramidal system, for example, with hemiplegia in the case of a cerebral stroke, and the Rossolimo reflex is a late manifestation of spastic paralysis or paresis.

Flexion pathological reflexes on the upper limbs. Tremner's reflex - flexion of the fingers in response to quick tangential irritations by the fingers of the examiner of the palmar surface of the terminal phalanges of the II-IV fingers of the patient. Jacobson reflex - Weasel - combined flexion of the forearm and fingers in response to a blow with a hammer on the styloid process of the radius. Zhukovsky reflex - flexion of the fingers of the hand when struck with a hammer on its palmar surface. Bekhterev's carpal-finger reflex - flexion of the fingers of the hand during percussion with the hammer of the back of the hand.

Pathological protective, or spinal automatism, reflexes on the upper and lower extremities- involuntary shortening or lengthening of a paralyzed limb during an injection, pinching, cooling with ether or proprioceptive irritation according to the Bekhterev-Marie-Foy method, when the examiner makes a sharp active flexion of the toes. Protective reflexes are often flexion in nature (involuntary flexion of the leg in the ankle, knee and hip joints). The extensor protective reflex is characterized by involuntary extension of the leg in the hip and knee joints and plantar flexion of the foot. Cross-protective reflexes - flexion of the irritated leg and extension of the other are usually noted with a combined lesion of the pyramidal and extrapyramidal tracts, mainly at the level of the spinal cord. When describing protective reflexes, the form of the reflex response, the reflexogenic zone, is noted. the reflex evoking area and the intensity of the stimulus.

Neck tonic reflexes arise in response to irritations associated with a change in the position of the head in relation to the body. Magnus-Klein reflex - increased extensor tone in the muscles of the arm and leg, towards which the head is turned with the chin, flexor tone in the muscles of opposite limbs when turning the head; flexion of the head causes an increase in flexor, and extension of the head - extensor tone in the muscles of the limbs.

Gordon reflex- delay of the lower leg in the extension position when inducing a knee jerk. Foot phenomenon (Westphalian)- "freezing" of the foot with its passive dorsiflexion. Foix-Thevenard's Shin Phenomenon- incomplete extension of the lower leg in the knee joint in a patient lying on his stomach, after the lower leg was kept in the position of extreme flexion for some time; manifestation of extrapyramidal rigidity.

Yaniszewski's grasping reflex on the upper limbs - involuntary grasping of objects in contact with the palm; on the lower extremities - increased flexion of the fingers and feet during movement or other irritation of the sole. Distant grasping reflex - an attempt to capture an object shown at a distance. It is observed with damage to the frontal lobe.

An expression of a sharp increase in tendon reflexes are clonuses, manifested by a series of rapid rhythmic contractions of a muscle or group of muscles in response to their stretching. Foot clonus is caused in a patient lying on his back. The examiner flexes the patient's leg at the hip and knee joints, holds it with one hand, and with the other hand grabs the foot and, after maximum plantar flexion, jerks the foot dorsiflexion. In response, rhythmic clonic movements of the foot occur during the time of stretching the calcaneal tendon. Clonus of the patella is caused in a patient lying on his back with straightened legs: fingers I and II grab the top of the patella, pull it up, then sharply shift it in the distal direction and hold it in this position; in response, a series of rhythmic contractions and relaxations of the quadriceps femoris muscle and a twitching of the patella appear.

Synkinesia- reflex friendly movement of a limb or other part of the body, accompanying the voluntary movement of another limb (part of the body). Pathological synkinesis is divided into global, imitation and coordinating.

Global, or spastic, is called pathological synkinesis in the form of increased flexion contracture in a paralyzed arm and extensor contracture in a paralyzed leg when trying to move paralyzed limbs or active movements with healthy limbs, straining the muscles of the trunk and neck, coughing or sneezing. Imitative synkinesis is an involuntary repetition by paralyzed limbs of voluntary movements of healthy limbs on the other side of the body. Coordinator synkinesis manifests itself in the form of performing additional movements by paretic limbs in the process of a complex purposeful motor act.

contractures. Persistent tonic muscle tension, causing limitation of movement in the joint, is called contracture. Distinguish in shape flexion, extensor, pronator; by localization - contractures of the hand, foot; monoparaplegic, tri- and quadriplegic; according to the method of manifestation - persistent and unstable in the form of tonic spasms; by the time of occurrence after the development of the pathological process - early and late; in connection with pain - protective-reflex, antalgic; depending on the damage to various parts of the nervous system - pyramidal (hemiplegic), extrapyramidal, spinal (paraplegic), meningeal, with damage to peripheral nerves, such as the facial one. Early contracture - hormetonia. It is characterized by periodic tonic spasms in all limbs, the appearance of pronounced protective reflexes, dependence on intero- and exteroceptive stimuli. Late hemiplegic contracture (Wernicke-Mann posture) - bringing the shoulder to the body, flexion of the forearm, flexion and pronation of the hand, extension of the thigh, lower leg and plantar flexion of the foot; when walking, the foot describes a semicircle.

Semiotics of movement disorders. Having revealed, on the basis of a study of the volume of active movements and their strength, the presence of paralysis or paresis caused by a disease of the nervous system, determine its nature: whether it occurs due to damage to the central or peripheral motor neurons. The defeat of the central motor neurons at any level of the cortical-spinal tract causes the occurrence central, or spastic, paralysis. With the defeat of peripheral motor neurons in any area (anterior horn, root, plexus and peripheral nerve), peripheral, or sluggish, paralysis.

Central motor neuron : damage to the motor area of ​​the cerebral cortex or the pyramidal pathway leads to the cessation of the transmission of all impulses for the implementation of voluntary movements from this part of the cortex to the anterior horns of the spinal cord. The result is paralysis of the corresponding muscles. If the interruption of the pyramidal tract occurs suddenly, the stretch reflex is suppressed. This means that the paralysis is initially flaccid. It may take days or weeks for this reflex to recover.

When this happens, the muscle spindles will become more sensitive to stretch than before. This is especially evident in the flexors of the arm and extensors of the leg. Hypersensitivity of stretch receptors is caused by damage to the extrapyramidal pathways that terminate in the cells of the anterior horns and activate gamma motor neurons that innervate intrafusal muscle fibers. As a result of this phenomenon, the impulses along the feedback rings that regulate the length of the muscles change so that the flexors of the arm and the extensors of the leg are fixed in the shortest possible state (the position of the minimum length). The patient loses the ability to voluntarily inhibit hyperactive muscles.

Spastic paralysis always indicates damage to the central nervous system, i.e. brain or spinal cord. The result of damage to the pyramidal tract is the loss of the most subtle voluntary movements, which is best seen in the hands, fingers, and face.

The main symptoms of central paralysis are: 1) a decrease in strength combined with a loss of fine movements; 2) spastic increase in tone (hypertonicity); 3) increased proprioceptive reflexes with or without clonus; 4) decrease or loss of exteroceptive reflexes (abdominal, cremasteric, plantar); 5) the appearance of pathological reflexes (Babinsky, Rossolimo, etc.); 6) protective reflexes; 7) pathological friendly movements; 8) the absence of the reaction of rebirth.

Symptoms vary depending on the location of the lesion in the central motor neuron. The defeat of the precentral gyrus is characterized by two symptoms: focal epileptic seizures (Jacksonian epilepsy) in the form of clonic convulsions and central paresis (or paralysis) of the limb on the opposite side. Paresis of the leg indicates the defeat of the upper third of the gyrus, the hand - its middle third, half of the face and tongue - its lower third. It is diagnostically important to determine where clonic convulsions begin. Often, convulsions, starting in one limb, then move to other parts of the same half of the body. This transition is made in the order in which the centers are located in the precentral gyrus. Subcortical (radiant crown) lesion, contralateral hemiparesis in the arm or leg, depending on which part of the precentral gyrus the focus is closer to: if to the lower half, then the arm will suffer more, to the upper - the leg. Damage to the internal capsule: contralateral hemiplegia. Due to the involvement of corticonuclear fibers, there is a violation of innervation in the area of ​​the contralateral facial and hypoglossal nerves. Most cranial motor nuclei receive pyramidal innervation from both sides in whole or in part. Rapid damage to the pyramidal tract causes contralateral paralysis, initially flaccid, as the lesion has a shock-like effect on peripheral neurons. It becomes spastic after a few hours or days.

Damage to the brain stem (brain stem, pons, medulla oblongata) is accompanied by damage to the cranial nerves on the side of the focus and hemiplegia on the opposite side. Cerebral peduncle: A lesion in this area results in contralateral spastic hemiplegia or hemiparesis, which may be associated with ipsilateral (on the side of the lesion) oculomotor nerve lesion (Weber's syndrome). Brain pons: If affected in this area, contralateral and possibly bilateral hemiplegia develops. Often not all pyramidal fibers are affected.

Since the fibers descending to the nuclei of the VII and XII nerves are located more dorsally, these nerves may be intact. Possible ipsilateral involvement of the abducens or trigeminal nerve. The defeat of the pyramids of the medulla oblongata: contralateral hemiparesis. Hemiplegia does not develop, since only the pyramidal fibers are damaged. The extrapyramidal pathways are located dorsally in the medulla oblongata and remain intact. If the chiasm of the pyramids is damaged, a rare syndrome of cruciant (or alternating) hemiplegia develops (right arm and left leg and vice versa).

For the recognition of focal lesions of the brain in patients in a coma, the symptom of a rotated outward foot is important. On the side opposite the lesion, the foot is turned outward, as a result of which it rests not on the heel, but on the outer surface. In order to determine this symptom, you can use the method of maximum turn of the feet outward - Bogolepov's symptom. On the healthy side, the foot immediately returns to its original position, and the foot on the side of hemiparesis remains turned outward.

If the pyramidal tract is damaged below the decussation in the brainstem or upper cervical segments of the spinal cord, hemiplegia occurs involving the ipsilateral limbs or, in the case of bilateral damage, tetraplegia. Damage to the thoracic spinal cord (involvement of the lateral pyramidal tract) causes spastic ipsilateral monoplegia of the leg; bilateral involvement leads to lower spastic paraplegia.

Peripheral motor neuron : damage can capture the anterior horns, anterior roots, peripheral nerves. In the affected muscles, neither voluntary nor reflex activity is detected. Muscles are not only paralyzed, but also hypotonic; there is an areflexia due to interruption of the monosynaptic arc of the stretch reflex. After a few weeks, atrophy sets in, as well as the reaction of the degeneration of paralyzed muscles. This indicates that the cells of the anterior horns have a trophic effect on muscle fibers, which is the basis for normal muscle function.

It is important to determine exactly where the pathological process is localized - in the anterior horns, roots, plexuses or in peripheral nerves. When the anterior horn is affected, the muscles innervated from this segment suffer. Often in atrophying muscles, rapid contractions of individual muscle fibers and their bundles are observed - fibrillar and fascicular twitches, which are the result of irritation by the pathological process of neurons that have not yet died. Since the innervation of the muscles is polysegmental, complete paralysis requires the defeat of several adjacent segments. Involvement of all the muscles of the limb is rarely observed, since the cells of the anterior horn, supplying various muscles, are grouped in columns located at some distance from each other. The anterior horns can be involved in the pathological process in acute poliomyelitis, amyotrophic lateral sclerosis, progressive spinal muscular atrophy, syringomyelia, hematomyelia, myelitis, and circulatory disorders of the spinal cord. With damage to the anterior roots, almost the same picture is observed as with the defeat of the anterior horns, because the occurrence of paralysis here is also segmental. Paralysis of the radicular character develops only with the defeat of several neighboring roots.

Each motor root at the same time has its own “indicator” muscle, which makes it possible to diagnose its lesion by fasciculations in this muscle on an electromyogram, especially if the cervical or lumbar region is involved in the process. Since the defeat of the anterior roots is often caused by pathological processes in the membranes or vertebrae, simultaneously involving the posterior roots, movement disorders are often combined with sensory disturbances and pain. Damage to the nerve plexus is characterized by peripheral paralysis of one limb in combination with pain and anesthesia, as well as autonomic disorders in this limb, since the plexus trunks contain motor, sensory and autonomic nerve fibers. Often there are partial lesions of the plexuses. When a mixed peripheral nerve is damaged, peripheral paralysis of the muscles innervated by this nerve occurs, in combination with sensory disturbances caused by a break in the afferent fibers. Damage to a single nerve can usually be explained by mechanical causes (chronic compression, trauma). Depending on whether the nerve is completely sensory, motor or mixed, sensory, motor or autonomic disturbances occur, respectively. The damaged axon does not regenerate in the CNS, but can regenerate in the peripheral nerves, which is ensured by the preservation of the nerve sheath, which can guide the growing axon. Even if the nerve is completely torn, bringing its ends together with a suture can lead to complete regeneration. The defeat of many peripheral nerves leads to widespread sensory, motor and autonomic disorders, most often bilateral, mainly in the distal segments of the extremities. Patients complain of paresthesia and pain. Sensitive disorders such as "socks" or "gloves", flaccid muscle paralysis with atrophy, and trophic skin lesions are revealed. Polyneuritis or polyneuropathy is noted, arising from many reasons: intoxication (lead, arsenic, etc.), alimentary deficiency (alcoholism, cachexia, cancer of internal organs, etc.), infectious (diphtheria, typhoid, etc.), metabolic ( diabetes mellitus, porphyria, pellagra, uremia, etc.). Sometimes it is not possible to establish the cause and this condition is regarded as idiopathic polyneuropathy.