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- An involuntary association between the
movements of paralysed limbs and other parts of
the body is a well known thing in cases of
hemiplegia. When, for instance, the leg on the
unaffected side is voluntarily moved, it often
happens that the paralysed leg moves with it,
and when a deep yawn occurs the paralysed arm
is frequently drawn across the chest with
great force. While the mechanism by which these
movements are probably produced has been
carefully studied the physiological reasons for
their existence do not appear to have received
so much attention, and, after briefly referring
to their mechanism, I shall endeavour to show
that, at any rate in some cases, these movements
have a definite history in evolution, and that
they were once useful for the ordinary purposes
of life.
-
- In the case of a complete hemiplegia due,
say, to destruction of the internal capsule, it
is instructive first of all to enquire what
changes have resulted from the lesion in order
to allow the associated movements to take place,
or, to put the question in another way, to
enquire what influences are present in health to
prevent them taking place.
-
- The answer to this question is to be found
by a consideration of the functions of the
pyramidal tracts which are destroyed in such a
lesion as that suggested above.
-
- These functions are in the main twofold; the
fibres conduct (1) impulses which give rise to
voluntary movements, and (2) impulses which
exercise a constant inhibitory effect on the
lower centres. When these fibres are destroyed
there is loss of voluntary power as seen by the
paralytic symptoms, and loss of inhibition as
seen by the rigidity and increased reflex
irritability. It is doubtless this loss of
inhibition which allows associated movements,
for otherwise there seems no reason why those
which occur in hemiplegia should not also occur
in health.
-
- With regard to inhibition in the case of the
respiratory centre, and the results of cutting
it off in hemiplegia, Dr. Hughlings Jackson's
observations may be referred to here(Lancet,
February 23, 1895).
-
- In hemiplegia Dr. Jackson found that during
ordinary or automatic respiration the amplitude
of the superior intercostal movements was
greater on the paralysed than on the sound side,
while in voluntary respiratory movements the
movements were greater on the sound side. Pierce
Clark (Am. Jour. Med. Science, December, 19O3.;
Sec also some remarks by Dr. Tudson S. Bury,
Lancet, December 19, 1903) has recently
confirmed this observation and gives the
following explanation. "In destructive lesions
of the internal capsule causing paralysis,
hemiplegic in character, the cortical inhibitory
control over the medullary respiratory centre of
the paralysed side is destroyed in greater part,
at least much more so on the hemiplegic side
than to that centre presiding over the sound
side; in consequence of this withdrawal the
uninhibited medullary centre overacts in
automatic. or ordinary respiration, hence excess
movements on the paralysed side. But in forced
conscious or volitional (cerebral) respiration
the movements of the thorax on the opposite
sound (or nearly so) side are greater."
-
- It may then I think be safely inferred that
the first step in the generation of patho1ogial
associated movements is the loss of inhibitory
impulses.
-
- Normal inhibition being removed, the second
step consists in the simultaneous action of the
cells on the paralysed side with those with
which the movement is to be associated, thus the
cells will act with their fellows of the
opposite side in the associated movements of the
two legs, or with the cells connected with the
respiration in the case of the movement of the
arm during yawning. On this part of the subject
Sir William Broadbent's classical observations
have thrown some considerable light (The British
and Foreign Medico-Chirurgical Review, 1886)
These observations were made with a view to
explain the escape of certain movements. in
hemiplegia, and Sir William Broadbent found that
the key of the solution lay in the fact that the
movements which escaped were those which
habitually acted with their fellows of the
opposite side, and he attributed this immunity
to the existence of free commissural paths
between their nuclei, so that impulses could
pass from the nucleus on the sound side to the
nucleus on the paralysed side.
-
- In other words, an impulse from either side
of the brain would, through the commissure,
reach both nuclei and so cause the bilateral
movements to be saved, when the unilateral
movements, which have no such convenient
commissures to help them, have perished. This
hypothesis, which has proved of such importance
in the study of neurology, will practically
explain the actual mechanism of the
posthemiplegic movements. The two stages in the
development of these movements would clearly be
(1) the removal of inhibitory influences on one
side by destruction of the pyramidal fibres; and
(2) action in conjunction with adjacent nuclei,
brought about by impulses passing along
commissural fibres. I would again lay stress on
the fact that the first step must be the removal
of inhibition, which has gradually become
developed as the education of the limbs for
isolated and special movements has proceeded,
for had this inhibition not been developed both
legs would probably move simultaneously like the
movements for closing the eyes.
-
- Another point to be observed is that the
constant presence of inhibitory influences leads
to gradual disuse of the commissural fibres
until finally it becomes difficult, or even
impossible, for impulses to pass along them at
all. This effect is well seen if we again for a
moment compare the effects of a hemiplegia on
movements for closing the eyes with movements
for the legs. Those for closing the eyes are
scarcely, materially altered, for the two sides
have not yet become educated to act
independently of one another; the commissural
path betwen their nuclei is easily traversed,
and the nuclei are in a condition to receive and
to act from the impulses that come along it. On
the other hand, the legs are so much in the
habit of being moved separately that their
commissural fibres have become disused, and when
the inhibition is taken off, as it is in
hemiplegia, the disused paths are of but little
use and the movements of the limb suffer in
proportion.
-
- But while Sir William Broadbent's theory
accounts for the mechanism of the movements
after inhibition has been removed, it will be
noticed that so far from all these movements
being beneficial like those of closing the eyes,
they are often useless and even actually
detrimental. Only to be able to move the two
legs together, though possibly little better
than not being able to move them at all, can be
of very slight use, and it is certainly both
useless and unpleasant to have the arm drawn
across the chest during the act of
yawning.
-
- The commissural fibres which allow these
movements to take place must once have had their
uses or they would not have been developed, and
therefore it is reasonable to suppose that
impulses which were of some importance once
flowed along them, and that as these impulses
ceased the paths gradually became disused. When,
however, the influences that keep the impulses
from flowing along them are removed, the old
disused routes are again traversed although the
results may no longer be advantageous to the
individual. These associated movements of
hemiplegia may then be looked upon as a faint
reflection of movements which have gradually
become obliterated in the process of evolution,
and I shall now endeavour to trace out how these
movements originated and what purposes they
previously served. In the first place evidence
seems to show that all movements were originally
bilateral. The passage of bilateral movements
into unilateral ones can be easily traced in
man, and in every one, many movements which were
primarily associated tend to become dissociated,
and the dissociated ones then become still
further specialised for particular
purposes.
-
- We have only to compare the arms and hands
of man with the forelegs and feet of animals to
realise this.
-
- Thus the question of loss of power in
hemiplegia may be approached from another
standpoint, and we may ask, not why some
movements escape in a unilateral lesion, but why
some are lost, for working upwards from the time
when all movements were bilateral it will be
seen that the escape of movements in a one-sided
lesion would be the natural thing to happen, and
that their loss is the result of a gradual
dissociation and specialisation. The involuntary
associated movements of the two legs in
hemiplegia are, according to this supposition,
the representation of the bilateral movements of
the legs which at one time served as the chief
means of progression.
-
- When bilateral symmetry was first attained
(which it was at apparently a very early period
of animal evolution), all movements including
those of the limbs were doubtless bilateral, and
this mode of progression still remains in
various animals, as in the leaping of frogs and
the hopping of many birds. Progression by
alternate movements of the legs is a later
attainment, and the tendency to revert to the
more primitive method may often be seen in
animals when they are under the influence of
excitement. The horse and the bull, for example,
usually walk or trot, but when angry or
frightened they tend to gallop. As the art of
walking by separate movements of the legs is
acquired, the movenents of the two forelegs
become associated with those of the two hind
legs, but in such a manner that the left
fore-limb moves in conjunction with the right
hind limb and the right fore limb with the left
hind limb.
-
- This diagonal association of the limbs is
still seen in man at the present day by his
tendency to swing the arms alternately with the
legs in walking. To abstain from swinging the
arms in this way is an effort and can only be
accomplished with some trouble (Sir William
Broadbent alludes to this point in his recent
"Hughlings Jackson" Lecture (Brain, Pt. ciii.).
He says: "I think a further exemplification of
the principle (i.e., the bilateral association
of nerve centres) exists in the cord, in fibres
which may be assumed to extend from the arm
centre of one side to the leg centre of the
other or vice versâ, which have to do with
the automatic swinging of the arms in walking
and running; which may, moreover, have to do
with the imperfect paralysis of the leg in
hemiplegia, and which certainly, in my opinion,
give the explanation of the circus movement of
the dog instead of hemiplegia in severe lesion
of the motor area.")
-
- Man has entirely lost the more primitive
mode of progression by the simultaneous
movements of both legs, and he never apparently
finds any reason to resort to it unless it be
when he jumps, and even here in most cases one
leg tends to hang behind the other. Such a mode
of progression would be of no advantage to him
after he assumed the upright position. But
although obsolete in health the old association
shows itself again when the inhibitory
influences which check it are removed by
disease.
-
- When the inhibitory impulses cease to exist
the memories of the old bilateral movements
assert themselves, but the paths have become
difficult to traverse and only a feeble impulse
can get through to produce a correspondingly
feeble movement (It seems probable that the
comparative escape of the leg in hemiplegia is
due to the existence of these commissural fibres
rather than to those connecting the arm and leg
as suggested by Sir William Broadbent).
-
- The circumstances which give rise to
involuntary movements of the arm during yawning
are not quite so obvious, for it is not apparent
at first sight why the two movements should have
ever been associated.
-
- That the occurrence of these movements is
dependent upon the removal of inhibitory
influences is clear from what has already been
said, and it is interesting to note that the
dissociation has not yet become quite complete
even in health, for the involuntary stretching
of the limbs during a yawn is familiar to every
one.
-
- In one instance I have observed that deep
yawning is occasionally accompanied by some
involuntary jerky movements of flexion of the
left arm, quite different to the ordinary
stretching of the limb and much more nearly
approaching the movements one sees in
hemiplegia. It is also interesting to note that
in this case it was the left arm which moved,
for in a right-handed man one would expect the
left arm to be less specialised and therefore
less strongly inhibited than the right.
-
- In hemiplegia the paralysed arm is often
drawn across the chest with very great force and
at the same time the leg may be drawn up. In
order to arrive at some conclusion with regard
to the meaning of this association it is
necessary to consider some aspects regarding the
development of the function of
respiration.
-
- If we go back to the fish we find the lungs
represented by a swim-bladder, the chief use of
which is to allow the fish to vary the depth of
its position in the water. Compression of this
bladder appears to be accomplished usually by
the lateral muscles of the body, though in some
cases there is a distinct muscular coat
developed in the bladder wall. The two pectoral
and the two ventral fins are the homologues of
the future limbs, and it is interesting to note
that the chief function of these is not yet one
of progression, but rather of balancing the body
of the fish, and in performing this duty thes
fins appear to act to a considerable degree in
connection with the condition of the air
bladder. Cuvier says: "The pectoral and ventral
fins do not appear of much use in the progress
of fishes, but they employ, them to preserve
themselves in a state of equilibrium or a state
of rest, and they extend them whenever they find
it necessary to correct the vacillations of the
body."
-
- The nerve supply of the air bladder in
fishes is the vague, as it is that of the lungs
in later development, and in some species this
nerve sends fibres to the pectoral and ventral
fins from its lateral branches. There are then
even in fishes, before any lung respiration is
developed, some signs of association between the
representatives of the future limbs and the
future lungs.
-
- Lung breathing appears at first to be
developed as a supplementary aid to branchial
respiration, and the fish or amphibian that
cannot obtain sufficient air from his watery
surroundings seeks more by coming to the surface
of the water and swallowing it ("Principles of
Biology," by Herbert Spencer, vol. ii., p.
835).
-
- Repeated deglutition of air bubbles finally
results in the differentiation of the lungs from
the swim-bladder, but it seems obvious that as
soon as the animal begins to feel the benefit of
exchanging its air in this way, and habitually
practises this method of obtaining it, the
getting rid of the air must be quite as much a
voluntary effort as taking it in. It is only
later that the respiratory acts will become
controlled by automatic centres. Respiration,
more especially expiration, will no doubt at
first be effected by the trunk muscles, and the
nervous mechanism employed will not at that time
be specially differentiated, and it is probably
these early centres further developed which
survive to the present day as -subsidiary
respiratory centres in the cord, of which more
will be said later.
-
- In making these early expiratory efforts the
animal would find it necessary to have some
fixed point for the muscles to act from and this
would naturally be obtained by fixing the limbs,
a piece of knowledge which is inherited by man
and put to practical use when he voluntarily
brings his extra respiratory muscles into play,
as in asthma.
-
- Another interesting piece of evidence
concerning the association between movements of
the limbs and respiration is furnished by the
Chelonia, to which class belong the turtles and
tortoises. In Owen's work on comparative anatomy
it is stated that the lungs of these animals are
lodged in a cavity the capacity of which is only
affected by the retraction and protrusion of the
limbs and tail, and that if a turtle is thrown
upon its bak, and makes an inspiration, its four
feet are erected, the breast bone is pushed
forward, and the cavity swells out wherever the
parts are soft, and it is suggested that all
this is done by the muscles of the extremities
moving their respective bones in an inverted
order; that is, the extremity becomes the fixed
point from which the other bonds move
(Respiration can also be carried on when the
limbs are motionless, apparently by acts of
deglutition. y. Owen's "Comp. Anat").
-
- Next, it will be well to consider the
subsidiary respiratory centres that still exist
in the cords of mammals, and which, no doubt,
represent centres that at one time took a very
important, if not the chief, part in the
functions of respiration. Sir Michael Foster, in
his text-book of physiology, states that in
young animals, under certain conditions,
respiratory movements may be carried out with
entire absence of the spinal bulb, and that
these rhythmical respiratory movements are
sometimes accompanied by rhythmic movements of
the fore and hind limbs.
-
- It should, however, be stated that Sir
Michael Foster for some reason does not consider
that these movements of the limbs are
respiratory in action, and owing to their
presence he doubts whether the experiments
really prove the existence of distinct
respiratory centres in the cord, but unless
there is any special reason for thinking
otherwise it would seem reasonable to believe
that the movements in question, represent an
association between the movements of the limbs
and those of respiration. Moreover, to some
authorities these centres have a higher
significance, for Sir Michael Foster goes on to
say that some consider them to be the chief
centres which the bulb merely governs. Anyhow,
this probably their position at one time, until
they graduallly lost their independence as they
came to be more and more under the control of
the higher centre.
-
- Because these centres are unable to carry on
respiration when the bulb is destroyed it must
not be too hastily assumed that they are
necessarily so useless when the mechanism is
complete, for it may be that under the influence
of the bulb they discharge duties which they are
unable to do as soon as that influence is
removed.
-
- To sum up, then, it would appear that the
evidence goes to show that respiratory movements
in animals were originally closely associated
with movements of the limbs, and it seems likely
that it is this association that accounts for
the presence of commissural fibres between the
nuclei which preside over th two movements. As
the respiration became more thoracic in
character its association with the legs would
become weakened, and then, later on, the
movements of the arms would gradually become
dissociated as they became educated to perform
more special movements, for the inhibition
required for these finer movements would
effectually prevent any movement taking place
with respiration, which, if allowed, would
obviously destroy the utility of the arms for
other purposes. At the same time the increasing
automatic action of the respiratory movements
would also tend to make ordinary respiration
independent of any support from the limbs except
in cases of difficulty, and thus the movements
of respiration and of the limbs, at first
intimately associated, would gradually drift
apart until finally, with the development of
inhibition on the one hand, and with the disuse
of the commissural paths on the other, the
association would practically altogether
disappear, but as soon as the inhibitory
impulses are taken off the limb again tends to
resume its old relations, the unused paths
become reopened and the old associations are
revived; In health these paths have still, in
this instance, been used a little during
yawning, so that their obliteration has never
been quite complete. Yawning is a peculiar
respiratory act in thany ways and is certainly
more automatic than ordinary breathing.
According to Sir Michael Foster the stimulus
in yawning probably acts upon the respiratory
centre itself; possibly the centres in the cord
also take a share in it, but in any case yawning
may be looked upon as a lower type of the
respiratory process than ordinary respiration,
and therefore the one with which the movement of
the arm would be likely to be longest
associated.
- Darwin's first principle in his work on
"The
Expression of the Emotions" is "that
movements which are serviceable in gratifying
some desire, or in relieving some sensation, if
often repeated, become so habitual that they are
performed, whether or not of any service,
whenever the same desire is felt, even in a weak
degree". I would then suggest that these
post-hemiplegic associated movements are in
keeping with this principle inasmuch as they
represent movements which were once serviceable,
but which have now ceased to be so. These
movements, though scarcely discernible in
health, have not, however, yet become entirely
obliterated, and they are still able to show
themselves clearly when the restraining
influences that normally check them are
removed.
- Nouvelle observation
de bâillement convulsif
périodique Liecey Le
Courrier Médical 1879
- Associated
movements in hemiplegia : their origin and
physiological significance Thomson HC
Brain 1903; 26;
515-523
- Etude sur
la pandiculation automatique des
hémiplégiques M Bertolotti
1905
- Mouvements
involontaires dans les membres
paralysés Pierre Marie et
André Léri
1911
- On certain tonic or
postural reflexes in hemiplegia with special
reference to the so called "associated
movements" Walshe
1923
- Le
diagnostic des maladies nerveuses Sir J.
Purves-Stewart 1939
- Is yawning a
brainstem phenomenon ? Wimalaratana HS,
Capildeo R. A stroke patient who stretched his
hemiplegic arm during yawning
Lancet 1988; 1; 8580;
300
- Assoctiated
reactions in the hemiplegic arm, Graham
Mulley Scand J Rehab Med 1982;
14; 117-120
- A single report
of an hemiplegic arm stretching related to
yawning Blin O, Rasol O, Azulay JP,
Serratrice G J of neurological
sciences 1994; 126; 225-227
- Yawning: a
possible confounding variable in EMG
biofeedback Oman RE.
- The yawning
and stretching sign in hemiplegics Lanari A,
Delbono O. Medicina (B Aires),
1983; 43; 3; 355-6
- Paroxysmal
kinesigenic dystonia associated with a medullary
lesion Riley DE. Mov Disord
1996; 11; 6; 738-40 & Mov Disord. 1997; 12;
5; 819
- Involuntary
stretching during yawning in patients with
pyramidal tract lesions: further evidence for
the existence of an independent emotional motor
system Topper R. European J
Neurology 2003; 10; 495-499
- Elévation
involontaire du membre supérieur chez
l'hémiplégique lors d'un
bâillement, appelée
hémipandiculation la thèse du
Dr Etienne Quoirin (Professeur
JP. Neauseptembre 2002 Poitiers )
Télécharger
pdf
- Comprendre
avec l'aide de K Ezure la coordination
respiration - marche
- Convergence
of central respiratory and locomotor rhythms
onto single neurons of the lateral reticular
nucleus Ezure K, Tanaka I
Exp Brain Res1997; 113; 2;
230-242
-
- Abercrombie
J, Gendrin A Des maladies de
l'encéphale et de la moelle
épinière Germer-Baillière
1835
- Abercrombie
J Yawning and apoplexy Medical Times and
Gazette 1863;1:656-661
- Bauer G. et al
Involuntary motor phenomena in the locked in
syndrome J Neurology 1980;223;:91-198
- Bertolotti
M. Etude sur la pandiculation automatique
des hémiplégiques Rev Neurol
1905;2(19): 953-959
- Blin O, Rasol O,
Azulay JP, Serratrice G. A single report of
an hemiplegic arm stretching related to yawning
J Neuro Sci 1994;126:225-227
- Brissaud
E, Pinard, A, Reclus P Pratique
médico-chirurgicale
Hémiplégie par A Souques Masson
1907, p538-539
- Brissaud
E Leçons sur les maladies nerveuses
Masson 1895, p458
- Darwin
E. Zoonomia 1801
- de
Buck Classification des mouvements anormaux
associés à
l'hémiplégie Rev Neurol
1899;6:361-365
- Furtado D.
Provocation spinale d'un réflexe de
bâillement. Rev d'oto neuro
ophtalmologie.1951;23(1):
- Ghika
J., Bogousslavsky J. Dissociated
preservation of automatic-voluntary jaw
movements in a patient with biopercular and
unilateral pontine infarcts Eur Neurol
2003;50:185-188
- Heusner A P
Yawning and associated phenomena Physiological
Review 1946;25:156-168
- Klippel M et
Monier-Vinard R. Hémiplégie
flaccide. Nouveau Traité de
Médecine. Masson. 1928 p 316
- Lanari A.,
Delbono O. The yawning and stretching sign
in hemiplegics Medicina (B Aires)
1983;43(3):355-35
- Liecey Nouvelle
observation de bâillement convulsif
périodique Le Courrier Médical
1879;29;334-336
- Liégey Deux
observations de bâillements intermittents
Gazette médicale de Strasbourg 1851;
p118-119
- Louwerse E
Forced yawning as a pseudobulbar sign in
amyotrophic lateral sclerosis J Neuroscience
Research 1998, sup, 392
- Mulley G.
Assoctiated reactions in the hemiplegic arm
Scand J Rehab Med 1982;14:117-120
- Ogle
JW. Arm rising during yawning The Medical
Times and Gazette. 28 february 1863 p 213
- Pierre
Marie La Pratique Neurologique
Hémiplégie, mouvements
associés Masson 1911, p477-480
- Pierre
Marie et Léri A. Mouvements
involontaires dans les membres paralysés
1911 Nouveau Traité de médecine et
de thérapeutique Brouardel, Gilbert,
Thoinot JB Baillière Ed 1911
p283-291
- Purves-Stewart
J. Le diagnostic des maladies nerveuses
1939
- Quoirin E.
Elévation involontaire du membre
supérieur chez
l'hémiplégique lors d'un
bâillement Thèse doctorat en
médecine Poitiers 2002
- Thomson HC
Associated movements in hemiplegia : their
origin and physiological significance Brain
1903;26:515-523
- Töpper
R, Mull M, Nacimento W Involuntary
stretching during yawning in patients with
pyramidal tract lesions: further evidence for
the existence of an independent emotional motor
system European J Neurology 2003;10:495-499
- Trautmann R. Le
bâillement Thèse Bordeaux; 1901-02;
N° 40; 86 pages
- Vulpian A
Leçons sur la physiologie
générale et comparée du
système nerveux faites au Museum
d'histoire naturelle. Rédigées par
E.Brémond. Paris, Baillière,
1866
- Vulpian
A Maladies du système nerveux Paris,
Doin, 1879
- Walshe FMR
On certain tonic or postural reflexes in
hemiplegia with special reference to the so
called "associated movements". Brain,
1923;46:1-37
- Wimalaratna HS,
Capildeo R. Is yawning a brainstem
phenomenon ? a stroke patient who stretched his
hemiplegic arm during yawning Lancet
1988;1(8580):300
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