Lorsque le malade bâille, le bras
paralysé accuse un spasme et s'étend
partiellement de même que le poignet et les doigts;
lorsque le bâillement est passé le membre
reprend sa position première
On
certain tonic or postural reflexes in hemiplegia
with special reference to the so called
"associated movements"
Walshe FMR , London
In earlier papers the writer bas endeavoured
to analyse in physiological terms the spasticity
resulting from pyramidal system lesions and also
the reflex movements in the lower limbs in the
two clinical forms of paraplegia, the extended
and the flexed. These phenomena were identified
with certain tonic and phasic reflex reactions
described by Sherrington. A similar detailed
analysis of the familiar associated movements
of the paralysed limbs in hemiplegia remains
to be undertaken on the same lines. In the
papers referred to above some preliminary
considerations on the subject were stated. Thus,
these movements were described as tome or
postural reactions, that is, as reflex
variations in muscle tone, rather than as
movements in the strict physiological sense.
This conclusion was based upon the following
considerations.
Neurolocists are learning froui Sherrington
to regard muscle tone as the basis of posture,
and decerebrate rigidity as a form of reflex
standing. In the earlier analysis of spasticity,
as it occurs in hemiplegia and in the extended
form of spastic paraplegia, reasons were given
for regarding it as physiologically identical
with experimentally produced decerebrate
rigidity. It was pointed out that all voluntary
purposive movements are accompanied by an
appropriate postural adjustment of the rest of
the skeletal musculature, and that in forceful
movements this adjustment or adaptation is
necessarily bilateral and widespread. Although
carried out under voluntary control, postural
adaptation is a function of reflex mechanisms
situated in the brain-stem, which are not put
out of action by the lesion which produces
hemiplegia and abolishes voluntary control of
the musculature on the affected side of the
body.
In these circumstances, we should still
expect postural reactions to occur when forceful
voluntary motor activities are carried out by
the musculature of the sound half of the body.
Now, however, deprived of cortical control, they
would occur in exaggerated intensity and
deprived of that fineness of adaptation which
that control ensures. It was concluded that the
associated movements of hemiplegia are phenomena
of this order, appearing in the muscles of the
affected side on certain voluntary movements of
the normal limbs, or on such semi-voluntary
movements as yawning. In other words,
associated movements, or, as we shall call
thein, " associated reactions," are released
postural reactions in muscles deprived of
voluntary control. [...]
We have chosen tonic voluntary activity of
the normal limbs as the type of stimulus most
effective in eliciting an associated reaction
but is not suggested that voluntary contraction
of other muscles may have a similar, if less
pronouneed, effect. Firm clenching of the
stiffening of the neck muscles, and such
quasi-involuntary activities yawning and
stretching and coughing, also produce
associated reaction. Further, voluntary
contraction of one of the limbs on the
hemiplegicside may be productive of an
associated reaction in the other. It is possible
also that the elevation of the shoulder,
abduction of the .. and flexion of the forearm,
which may accompany the attempt patient
voluntarily to extend his clenched fingers in
the affected may be of the nature of an
associated reaction. In this case, how as we
shall see when discussing Marie and Foix's
classificati on syncinésies, another type
of movement may be in question every instance
the voluntary contraction which constitutes the
stimuli for an associated reaction, whether it
be in the limb or trunk- must be forceful and
maintained.
The form of the associated reaction.- As
Riddoch have pointed out, the associated
reaction may be very widespread it is with the
limb reaction that we shall mainly deal, because
more readily capable of accurate observation and
recording than contraction in trunk muscles, and
is therefore better adapted for determination of
the nature of associated reactions as a whole.
It shall see later, it is essential in studying
associated reactions the conditions of
examination shall be constant. The folowing
description applies to the reactions obtained
from a patient his back with the head in the
median position. The normal are extended and
supported on the bed at the patient's side. The
h then held by the observer and the patient
commanded to give a sfeady, and maintained
grasp. No excursion of the arm occur in these
circumstances the paralysed arm as it lies
resting, semi across the patient's body, is seen
to go into strong tonic cont after a short
interval. In this contraction every muscle of
the and limb girdle may be both felt and seen to
contract. In the of instanced the flexors of the
forearm are most affected, a slow movment of
flexion at the elbow results, and the new
posture taken maintained more or less steadily
until the patient is told to re voluntary grasp.
In addition to flexion of the elbow there is
free some elevation of the shoulder and either
adduction or abduction upper arm. In the former
case the forearm and hand pass across body
toward.the sound side, in the latter the forearm
is lift the body and moved away from the normal
side. [...]
In this connection it is interesting to note
the form of associated reaction in the
paralysed arni which accompanies yawning and
stretching. It is exceptional to find a
subject with residual spastic lierniplegia from
whom a history of spontaneous movement of the
paralysed arm or hand on yawning cannot be
obtained. In many cases, coughing is also
accompanied by such a reaction. Every patient
whom the writer has questioned on this point,
with a single exception, has stated that the
movement of the hand and digits in these
circumstances is one of extension. This is often
complete and is accompanied by fanning of the
fingers. The forearm may be extended, but more
commonly flexes and is raised up in front of the
patient. Whenever the writer has observed this
reaction to yawning, extension and separation of
the digits have occurred. Moreover, two patients
volunteered the statement that when the fingers
are extended and abducted during a yawn they are
able to flex and extend them rapidly, a thing
they were unable to do at any other time.
Indeed, one man added that he always waited
for a yawn so that he might exercise his
fingers in this way. In an earlier reference
to this detail, the general inference was
suggested that unilateral muscular contraction
evoked an associated flexion, while such
bilateral muscular acte as yawning evoked
associated extensior. In the light of the more
recent observations recorded here, this
generalization must be abandoned, yet it remains
a striking fact that the force of muscular
activity most commonly producing associated
extension the digits is bilateral. In this case,
the stimulus may be tonic contration of the
diaphragm.......
Is yawning a
brainstem phenomenon ? Wimalaratana HS,
Capildeo R. A stroke patient who stretched his
hemiplegic arm during yawning
Lancet 1988; 1; 8580;
300
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